Music intervention as system: Reversing hyper systemising in autism spectrum disorders to the comprehension of music as intervention

Medical Hypotheses 82 (2014) 40–48

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Music intervention as system: Reversing hyper systemising in autism spectrum disorders to the comprehension of music as intervention Artur C. Jaschke ⇑ Department of Clinical Neuropsychology, VU University Amsterdam, 1081 BT Amsterdam, The Netherlands

a r t i c l e

i n f o

Article history: Received 6 August 2013 Accepted 5 November 2013

a b s t r a c t This paper seeks to combine the notion of the Empathising–Systemising (E–S) theory and the resulting twist from the executive dysfunction theory in autism spectrum conditions (ASC) in light of music intervention as system. To achieve these points it will be important to re-visit, nonetheless briefly, the above mentioned theories and re-define music intervention in the light of these. Furthermore there is the need to adjust the executive dysfunction theory to a theory of dysfunctioning executive functions. These notions will create a different understanding of music intervention in this context, allowing the development of future and existing music intervention programs applied clinically. These applications will evolve around a structuralised approach to music intervention as system, proposing five consecutive systems. It will therefore argue the aspects of expanding existing theories in ASC together with the call for generalised interventions to better assess autism from a theoretical point of view. Theories have to be updated in a time of fast and ever-changing development. Ó 2013 Elsevier Ltd. All rights reserved.

Introduction [


] to understand this theory we need to turn to [


] the concept of systemizing. Systemizing is the drive to analyse or construct systems. These might be any kind of system. What defines a system is that it follows rules, and when we systemize we are trying to identify the rules that govern the system, in order to predict how that system will behave. - [1, p. 630].

Autism spectrum disorders or conditions (ASD) are neurodevelopmental conditions, which affect 1 in 150 births in 2007 to 1 in 88 in 2010 to 1 in 70 in 2013, thus being more common than paediatric cancer, diabetes and AIDS combined [2–4]. Causes of this disorder can be traced back to genetic defaults affecting brain maturation processes, resulting in numerous dysfunctions within the wide understanding of executive functions1 and therefore the quality of life over the life span. Children and adults alike affected by this disorder suffer mostly from social incapability and difficulties in the execution of everyday functions such as planning, working memory, attention, problem solving, verbal reasoning, inhibition, mental flexibility, multi-tasking, initi⇑ Address: VU University Amsterdam, Department of Clinical Neuropsychology, Van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands. Tel.: +31 (0) 6 421 653 00. E-mail address: [email protected] 1 Executive functions are seen here as the sole neuro-cognitive processes and therefore disconnected from the executive dysfunction theory. This relationship will be discussed later in this paper. 0306-9877/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.mehy.2013.11.001

ation and monitoring of actions [5–7]. Additionally there are strong social impairments, stereotyped interests and activities observed, which can be seen as a direct result of the deficiencies in the above mentioned neuro-cognitive functions [8]. This wide array of impairment within the whole of the autistic spectrum makes it extremely difficult to explain and further, categorise this condition in terms of intervention. Nonetheless, numerous theories have been described to attempt the explanation of this still oft misunderstood disorder. The three ground pillars in this context are Theory of Mind [9], Weak Central Coherence [10–12], executive dysfunction [13,14]. In addition to these fundamental, yet not complete attempts of explaining ASD, one has to add the intense world theory as proposed by Markram and Markram [15], as it adds a defined neurobiological level. The first two, Theory of Mind and Weak Central Coherence, are among the most consolidated and recognised. Baron-Cohen and colleagues [16], introduced Empathising–Systemising [16], as another possible explanation for ASD. This theory, based on hyper perception and processing falls in line with the intense world theory and both will be discussed in more detail below. Taking these theories together a common pattern emerges, which in itself could be a trait of the autistic spectrum as broadly indicated by the E–S theory [16]; all of the above are systems within themselves. These theories – as is understood by the definition of a system – encompass structure, behaviour and connectivity, thus serving a function and following sets of rules. Henceforth one can follow one of the earliest descriptions of systems in conjunction with the autistic spectrum by identifying it

A.C. Jaschke / Medical Hypotheses 82 (2014) 40–48 [


] in der Fülle der Erscheinungen des Lebes, die voller Gegensätze sind, die mit verschwimmenden Grenzen in einander übergehen, sucht der denkende Mensch dadurch einen festen Standpunkt zu finden, dab er den einzelnen Erscheinungen einen Namen gibt, sie abgrenzt gegen die anderen Erscheinungen, Zusammenhänge, Ähnlichkeiten und Gegensätze feststellt, kurz, die Dinge in eine Ordnung, in ein System bringt. - [17, p. 1].

Here we do not argue the autistic spectrum itself as a system, but the factors describing and the interventions targeting it. Therefore can these points be seen as self-sustained systems following certain rules, allowing to investigate parameters within these systems and more so their similarities and differences. Our motivation for this specific concern addressing and defining music intervention in this context is rooted in (1) the lack of evidence and (2) the oft-misunderstood application of music intervention in an oft misunderstood condition [18]. Consequently, we will argue music as system, dividing it into subcategories, setting the tune for unified parameters. These will in turn contribute to the understanding of music intervention as system and its application on the huge diversity within the autistic spectrum. As a result we allow dissecting music intervention into attributes, which can be applied in clinical settings by using the suitable music intervention system addressing a particular property on the autistic spectrum. This paper addresses this relationship from a theoretical standpoint, serving to ignite the discussion within the field of music intervention and autistic spectrum disorders. The Empathising–Systemising (E–S) theory The E–S Theory is based on the two hypotheses of hyper structuralisation and hyper empathising in ASD, both of which address two main aspects of the autistic spectrum [19]. This was extended into the extreme male brain theory, which accounts for severe neural differences in the male brain in comparison to the female brain [19]. In turn it explains the underlying mechanisms of the E–S Theory, by placing gender specific traits to either brain; empathising is seen more as a female trait and systemising more as a male trait. Even though these characteristics echo differences in gender personality traits as argued by Nettle [20], it equally seems to pursue a rather black and white view of something as complex as the autistic spectrum. Nonetheless, it allows classifying autistic traits in the light of empathy and systemising to give an indication, if not allow a deeper insight into the possible underlying processes of autism. It therefore argues difficulties in communication and social interaction in ASD’s, by falling back on delayed or distorted empathy and pointing out the strengths through superior skills in systemising [19]. Application of this theory is resting on the discrepancy between these two aspects of ASD, determining the likelihood of an ASD [1], while sharing the same idea as the weak central coherence (WCC) theory [10]; a difference in cognitive style [11]. The difference between these two theories is that whilst the WCC theory sees people with autism spectrum conditions as drawn to detailed information (sometime called local processing) for negative reasons (an alleged inability to integrate), the E–S theory sees this same quality (excellent attention to detail) as being highly purposeful: it exists in order to understand a system. Attention to detail is occurring for positive reasons: in the service of achieving an ultimate understanding of a system (however small and specific that system might be). - [1, p. 631].

In this light, detaching this statement from its seemingly underlying property of the extreme male brain theory, one can by applying music interventional systems (to be specified below) appeal to this unique property of the autistic condition. Even though Kreutz and colleagues [21], have extracted a music related parameter in their music empathising and music systemising theory linked to E–S, their focus was based on the differences in music preference, rather than in the creation of a music based intervention.

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Executive dysfunction theory The title ‘‘executive function’’ is an umbrella term for the mental operations, which enable an individual to disengage from the immediate context in order to guide behaviour by reference to mental models of future goals.’’ - [14, p. 477].

The theory of executive dysfunction (ED) has been pioneered in the context of ASD, comparing it against the established Theory of Mind (ToM) by Firth [10]. It is based on the actual impairments in social and behavioural development in individuals on the autistic spectrum, by focusing on the neuro cognitive mechanisms underlying these impairments in the frontal lobes. Executive functions or the dysfunctions of these are associated with mechanisms controlling planning, working memory, attention, problem solving, verbal reasoning, inhibition, mental flexibility, multi-tasking, initiation and monitoring of actions [5–7]. Nonetheless, the theory of executive dysfunction proposes one of the most solid explanations for the above-mentioned impairments, still valid today. Most of these social and behavioural deficits, which can be observed in individuals on the autistic spectrum, are directly linked to these mechanisms found and associated in the frontal lobes. Therefore, the ED theory states that the difficulties of executing certain social as well as behavioural tasks by individuals with an ASD, are directly linked to their executive function [13,14]. Consequently, this theory does not allow a margin within this (dys) function. This point will be further discussed below in this paper, by redefining the executive dysfunction theory into the theory of dysfunctioning executive functions. This will imply that executive functions (EF) have to be seen as a stand-alone understanding of the neuro cognitive mechanism per se and not as a function in terms of social and behavioural difficulties. Therefore, incorporating the E–S theory into the ED theory will create a deeper understanding of the autistic spectrum. Against this backdrop it creates a cognitive environment, whereby the autistic mind has the ability to hyper-systemise. It will be further hypothesised that based on a slower reaction of executive functions, these cannot be seen as a dysfunction per se, but show a delayed effect after having repeatedly tried to explain the world as experienced by the autistic mind in a unique and specific own way. Therefore, Gepner and Feron’s [22] hypothesis stands, stating that the autistic spectrum is [


] a world changing too fast for a mis-wired brain [


]. - [22, p. 1227].

In line of this argument, the intense world theory [15] supports the claim of a slower, yet more centralised processing of incoming stimuli. As has been shown in the domain of visual processing, the autistic individual has the ability to see the tree (local) before realising – or at least after a significant delay – the whole forest (global) [23]. Applying these so called local processing schemata to the auditory field, the here proposed hypothesis of music as a system, exploits the local-perceptual field in ASD, by introducing individual aspects of the whole. In more detail, learning about the building blocks that encompass all of what music can be in a clinical setting. The understanding of music intervention in the context of ASD Even though there have been numerous therapeutic approaches such as cognitive behaviour therapy [24,25] or Auditory Integration Training [26] to mention only two, music therapy appears to show the strongest effects [27].2 Music intervention however, is mostly based on anecdotal recalls of effects and it is extremely difficult to convince policy makers of its effects, while lacking an empir2 Please refer to Treatments and Therapies for ASD currently under scientific evaluation by Research Autism, United Kingdom, for more treatment suggestion.

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ical research history. Nonetheless do meta analyses reviewing music intervention in ASD show positive effects and it [


] has been shown to be superior to similar forms of therapy where music was not used, and this may be indicative of a specificity of the effect of music within music therapy. - [27, p. 9].

Regardless of the positive effects of music therapy and the apparent superiority of music in this context [27], it is still not fully clear, if music as such is carrying these attributes or if they have to be accredited to other functions, e.g. cognitive or physiological [28]. Resulting from a recent systematic review on the relationship between music and the transfer effect [29], this gap became even wider. As argued by Jaschke and colleagues, it is difficult to claim an overall effect size of music on additional cognitive domains (far transfer) such as mathematics, intelligence or memory. This is, as a lack of existing sufficient discrimination of sub domains of the above-mentioned cognitive domains of for example mathematics and the effect of music thereof [29]. Nonetheless do these authors not negate a positive outcome, but raise the aspect of a more thorough examination of the effects of music education and/or intervention. This difficulty of explaining the influence of music in neurotypical children (NT), makes it even more so difficult to explain a positive effect on individuals with autism, due to the neurodevelopmental nature of this condition. Nevertheless, the effects for everybody who works and has worked with music intervention and autistic individuals are clear-cut. Effects encompass improvements in communicative skills, social interaction with their peers and the obvious delight and pleasure participants experience when exposed to music interventions [30,31]. Therefore, there exists a need to research this form of intervention more thoroughly. Research designs working with randomised control trials, which are virtually non-existent in autism research [32], will give more insight into the effects of music on ASD’s. To achieve this however, one has to firstly acknowledge the different forms of music intervention, which can be applied. Clinical and therapeutic applications are endless and it would exceed the scope of a lifetime to gather all possible ways and variations of this intervention. Central aspects however, are listening and active music participation/making, [33]. Kern and Humpal eds. [31], have gathered the most recent and widespread interventions in their book on Early childhood music therapy and Autism spectrum disorders; Developing potential in young children and their families. The authors discuss four treatment approaches, whereby treatment has to be seen as quality of life improvement rather than the actual attempt of treating ASD. Applied behaviour Analysis [34,35], Social Stories [36], The Nordoff–Robbins method [37] and DIR/Floortime [38] are discussed and a direction into working with children on the autistic spectrum using music is given. While these approaches interact directly with the children and their social, communicative as well as emotional capabilities, they do not address all of the potential music has to offer to cover the whole of the autistic spectrum. Effects of noncontingent Music on vocal stereoptypy and toy manipulation have been discussed by Lanovaz, Sladeczeck and Rapp [39], however, their elegant findings are based on a small population (N = 4) and therefore it is difficult to acknowledge a full coverage of the whole of ASD. More so the American National research Council [40] and Prizant et al., [41] pointed out that ‘‘not all children benefit equally from any approach’’ [41]:p. 296. The variety of music interventions for clients on the autistic spectrum therefore calls for a paradigm shift in the application of these therapies. There should be the time taken to analyse the individual needs and merits of each child and the to be applied therapy. To be able to do so, one needs not only to understand the autistic child, which is nearly impossible as the

heterogeneous nature of autism makes it extremely difficult, but more so the different possibilities music intervention can offer as a heterogeneous system itself. Geretsegger, Holck and Gold [42] have made a promising start, by introducing a study protocol for a randomised controlled trial (RCT) with improvisational music therapy. Even though the author’s use a possible form of music intervention, the protocol addresses the need for RCT’s as was argued above. The need for such RCT’s is further strengthened by Gadberry [43] who has conducted a survey on augmentative and alternative communication (ACC) during music therapy. This survey has revealed that only a small number of music therapists use ACC’s such as additional pictures or symbol boards for means of communication. This lack of additional means of expression addresses the issue of music as communicative medium and therefore questions the need of ACC in combination with music as intervention. Nonetheless, it is important to be able to find a form of communication with the client, is it by means of music alone [30,39] or additional means such as ACC [43]. In this light the following chapters will be based on the fundamental aspect of ASD as well as music; heterogeneity. We will argue music and music intervention as a system, which is constructed of sub systems all addressing a certain domain of music. Defining music intervention as a system will allow future research to extract parameters, which will create a benchmark in the development of coming interventions. Music intervention as system Extracting possible parameters, which allow a translation of music, intervention and the combination of both into a system is grounded in the understanding, a system has to encompass. A system follows rules, while being dependent on behaviour, connectivity and the urge to serve a function. Arguably one can detect certain rules a musical piece may follow, while being presented in a given context, following certain behavioural factors, grounding in connectivity of the individual parts, rhythms, timbers or even individual notes. Consequently, one would agree on certain parameters, which would be, debatably, the benchmark of the understanding of music. Nonetheless, are we aware of the fact that such a pseudo definition comes with more difficulties than solutions to the overall question of what music is. However, for the purpose of our hypothesis, music intervention will be seen as a system to be applied as a ground stone in the development of intervention parameters, thus staying with the above assumption of music. Intervention faces a similar array of difficulties in the application of it as a system. Both, music and intervention are dynamic terms, with both grounding on the subjective (1) understanding, (2) emotional and/or physical reaction to it, (3) processing and (4) subconscious factors. Nevertheless, intervention is a more agreed upon concept, with clearly defined comprehensions and applications; therefore, intervention is defined as [


] an act performed to prevent harm to a patient or to improve the mental, emotional, or physical function of a patient. A physiologic process may be monitored or enhanced, or a pathologic process may be arrested or controlled [


]. - [46].

The combination of both terms into music intervention therefore creates a double edged sword by having on the one side a dynamic attribute which is difficult to ultimately define, due to its plasticity (music) and on the other a dynamic attribute, which allows a clear definition (intervention). Albeit these two seemingly strong differences – following the metaphor – we will forge these two attributes together with their shared characteristics to create the understanding of music intervention as system. This in turn will be based on subcategories, allowing an application on the dif-

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ferent properties of the autistic spectrum. For this purpose we have divided the music intervention system into seven consecutive bottom-up subcategories; collectible, mechanical, numerical, natural, motoric, social and abstract music systems. Each of these may stand alone or can be seen as consecutive building blocks to create association processes with music leading to a successful application of it. Collectible music systems When applying music intervention to individuals with ASD, one has to account for certain complications. A major impediment can be hyper sensibility to music, which will hinder instead of support a development. Individuals with hypersensitivity to music perceive it as is believed as unpleasant. This statement however, is based on the observation of the individuals, who react repulsive to it [47]. Against this backdrop, reapplying Gepner et al’s [22] hypothesis of stimuli crossing the autistic brain too fast to be appropriately processed, one can argue music as one of these extremely fast and ever changing stimuli. This in turn would explain the repellent behaviour of individuals on the autistic spectrum towards it. In this light, one does not want to lose the full potential of music intervention and has to apply it in a rather altered way. As a result one can apply music intervention as a collectible music system; ‘collecting’ music related items, such as LP/CD covers or sheet music. An interest in these can be awoken and through this approach, link the favourite cover series to the music played and advance through an association process to reduce the hyper sensibility to a sensibility to music, thus be also applied to individuals in the spectrum without a hyper sensibility. Although this association process can be explained through the audio-visual loop in the brain and existing strong evidence of combined audio and visual stimuli as memory enhancing [48], it remains difficult to understand a clear relationship of these in the autistic brain. Mechanical music systems Falling into a similar line as the collectible music system, a mechanical music system will follow its attributes of understanding the structure and what is essentially ‘behind’ the music. Key aspects are, why do certain melodic progression follow a certain hierarchy, or why are cadenzas following a certain fixed structure? Within this understanding it is not only important to see the mechanical attributes of how a musical piece works, but additionally a historical and interpretational aspect arises. Furthermore can this idea be expanded into the comprehension of musical instruments as representations of mechanical processes within the music and as a direct cause and effect on the instrument; e.g. plugging the D string on a Bass while holding the 3rd fret down, will result in a change of pitch. Consequently does the mechanical aspect of music and of the instrument build a slow introduction into the understanding of individual notes and therefore a preparation of the autistic brain for the fast changing stimulus (read: music). Here as well, one does not have to listen in first instance to the music or sound, but can gradually build resilience to the ‘unpleasant’ sounds by creating associations of the mechanical structure of music in conjunction with the perceived or natural music system as will be further argued below. Notwithstanding, a juxtaposition arises. Applying music intervention, which in itself holds the connotation of having to actively listen to the music in order to be actively engaged with it, has to be revised. Therefore active engagement with music will have to encompass more than the listening or making aspect. It has to be the conscious interaction between all forms surrounding the musical stimulus. Consequently, a mechanical understanding of music as well as a collectible aspect

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of the same is a as valuable cognitive engagement in ASD’s as the sole listening or playing characteristic of it. Numerical music systems Following up on the above mentioned systems, one can introduce the numerical music system. Here one can apply the understanding gained from collectible and mechanical aspects of music intervention into an even deeper, more mathematical comprehension. As is widely know has the first relationship of mathematical values and music been established by early Pythagorean theory [49]. This theory shows the relationship of mathematical rations to musical pitch relationships or in other words, intervals (please see Table 1 for examples). Marking a fundamental understanding of the relationship of notes and therefore the comprehension of music, several analytical tools have emerged, based on mathematical structures, of which the Schenkerian [50], appeared as one of the most related to clear mathematical relationships and in turn most controversial. Discussing this controversy would exceed the purpose of this paper. Nonetheless Schenker’s theory is mentioned as it forms a fundamental part in creating an understanding of the numerical music system applied in ASD’s. Of note are also tuning relationships of instruments following Fibonacci chord series [51] or Pythagorean tuning [52]. All which potentially can be understood in the context of a system or systemising by itself. Applying a numerical comprehension of music, following hierarchical structures as proposed by Schenker [50] and later Lehrdahl and Jackendoff [53], one can translate these interactions into behavioural patterns forming reparative structures. Being able to explore these repetitive behaviours music can take, it can be matched to the repetitive behaviours on the autistic spectrum. We are aware that this is based on assumption, whereby the origin of repetitive behaviours in autism is not fully understood, not falling into the trap of saying explained. Nonetheless, following the logic of the above definition of music, intervention and system, one arguably internal behavioural pattern can create an association with another external pattern of a stimulus or intervention, giving (1) insight into the behaviour per se and (2) work with/against/in conjunction with it. Therefore can a therapeutic approach, whereas the participants interest of, here mathematical structures is taken and imposed on a external stimulus, be a valuable tool in linking one enhancing stimulus (music) with the interest of the individual. Natural music systems The term natural can be interpreted in many different ways. Here however, we have chosen to apply it as the ‘natural’ perception of sound. It encompasses the process of how we perceive music and further the understanding of how we process it. This notion is unfortunately not complete and ongoing research in this domain is shedding new insights into this area every day. However, we can work with the knowledge we have gained so far about the perception of music. Understanding, or at least, being aware of the basic neural processes and possible effects, music can evoke. We know that music has a strong influence on the neurotypical individual [54–56]. More so there are continuous reports about the positive effects of music on individuals with an ASD as was shown in several reports and meta analyses [27,33,57,58]. Consequently, the simplest form of music intervention is the most natural to us humans; simply listening and enjoying music. Taking away the above mentioned hyper-sensitivity to sound – possibly be bridged by the aforementioned systems – one can observe a world of effects and reaction across the whole of the spectrum. For that reason does the natural music system appeal to our innate understanding and ability to appreciate music [59]. Even though, this particular argu-

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Table 1 Examples of mathematical pitch relationships. Common name

Example name Hz

Multiple of fundamental

Ratio within octave

Fundamental

A2, 110 A3 220 E4 330 A4 440 C]5 550 E5 660 G5 770 A5 880

1

1/1 = 1

2

2/1 = 2 2/2 = 1 3/2 = 1.5

1200 0 702

5

4/2 = 2 4/4 = 1 5/4 = 1.25

1200 0 386

6

6/4 = 1.5

702

7

7/4 = 1.75

969

8

8/4 = 2 8/8 = 1

Octave Perfect fifth Octave Major third Perfect fifth Harmonic seventh Octave

3 4

ment still remains unresolved, there can be a lot learnt from the perceptual attributes of an individual on the spectrum. A direct link to this innate musical understanding is based on one possible cause of ASD’s. It is grounded in genetic3 and/or neural dysfunction of not only ‘younger’ brain regions such as the prefrontal cortices, but deeper, more ‘ancient’ structures like the Thalamus and the Brainstem [54,60,61]. This appeals to the developmental side of how we perceive music and the long lived argument of music as nature or nurture [59]. The understanding therefore, of a neurodevelopmental condition such as autism in juxtaposition to the neurotypical understanding of music listening, forces the discussion away from dissecting the stimulus (read: music) to a more thorough and detailed analyses of its effect on these ur-structures of cognition and behaviour. Listening to music, therefore allows structuring the world around the participant of music intervention in his/her own way. It is their understanding and rate of how and when to process it, outside a world, which is trying to impose its pace onto a hyper-systemiser trying to understand its parts. Motoric music systems Building on our innate or natural music system triggered in deep structures of the brain, adds another dimension to applied music intervention. Active music making is the embodiment of the sole listing aspect to music. It requires an active engagement and interaction with the stimulus, not necessarily understanding its marrows, but being able to understand it as a so called ‘‘proxy language’’ in the context of autism spectrum disorders [30]: p.289. The effectiveness of active music participation on the brain and in turn on behavioural development of individuals with autism is extraordinary. [


] in four or five seconds of abstract sound, she manages to acknowledge my presence, yet, through her own wit and imagination, trumps what I have [played] and assumes control [of the conversation]. - [30, p. 293].

As Ockelford describes here, there is a strong interaction between the two ‘conversation’ partners. They both acknowledge each other, notice a message coming from the opposing party and react upon it. This of course is an astonishing example of communication between the therapist/researcher and an individual with ASD. Away from the direct ‘‘conversational’’ aspect, there is the developmental trait of active music making. To play music, a 3 Only 10% of all cases are linked to a clear genetic mutation, as was expressed by Liptak.

Cents within octave 0

1200 0

whole array of brain areas is involved and stimulated. Besides the auditory cortex, which perceives the sound, main motor representation areas, areas of the prefrontal cortex involved in executive functions, somato-sensory areas, the hippocampus, the amygdala, cerebellum, thalamus – and the list continues – are involved in the process of making music [28,54,56,62,63]. These processes are obviously intact in individuals on the spectrum, whilst on their own, some of them like for example executive functions, seem impaired [13,64,65,66]. Consequently it seems as music is recruiting areas of the brain effectively, which otherwise show dysfunctions. The answer to this hypothesis remains unresolved and further research will help deciphering this enigma. It is through the analysis of music making as interventional tool in ASD and other neurodevelopmental or degenerative disorders, where the promise to an answer for a new generation of music scientist lies. Social music systems Music has the unique ability to create a social identity and understanding in the development from childhood to adulthood. This supports the development of strong social intelligences and the conceptualisation of social interactions [67,68]. Together with the above described musical systems the social aspect applies and contributes to all. Sharing, playing, listening, analysing, all of these traits illustrated, have the potential and strong need to work amplified in a group setting. This places music as a social system at the top of the pyramid. Music helps engaging with each other, it requires the individual to listen and to communicate. This happens in the music interventional setting as practised in numerous ASD centres around the world. Even though it is bound to the rules of a system, it allows a clear communication between the parties involved, without constricting them. This can be attributed to the earlier proposed definition of music and intervention as both solid and dynamic terms, which both blossom in light of social interaction. In individuals with an ASD, it can be a long process of learning to understand this social interaction, but it is about making the (social) world understandable for the individual and not superimpose an idea or concept, which seems ‘all so logical and normal’ to the neurotypical [69]. Music intervention system: an abstract model with clear results Whereas systemising music intervention appears as a abstract thought, results tend to speak another language. If taken into account the systematic approach of the above described interventional systems, the clinician or music therapist can see the

A.C. Jaschke / Medical Hypotheses 82 (2014) 40–48

reflection of these in everyday practise as is described only briefly in the mentioned examples. A total review of all case reports would exceed the scope of this paper. The reader however, should feel encouraged to review the vast amount of literature. Returning to the structuralised approach of and to music intervention, including different building blocks is the key to a successful intervention containing an abstract multi-sensory stimulus such as music [70]. How can this be understood in the light of music intervention as system and the wider picture of clinical application? This poses a difficult question, whose answer is not as straightforward as could be expected having laid out a systemised theory of music intervention. First, there is no unified clinical definition of music, therefore creating a model based on a systemised approach seems to lack the fundamental understanding of the stimulus per see and second its comprehension in a intervention setting. This problem was hinted at in Chapter 2 of this paper and will be further explored to create the basis for the re-definition of the executive dysfunction theory in light of music intervention as system. Following the consensus stated earlier in this paper and its parallels to clinical music literature [28], creating an intervention, which is grounded in a consecutive manner, allows different processes to take place. Different stages of development can be observed, whereby the accelerating in one stage of the music intervention system as described, allows proceeding into the next stage. Therefore, the achievement can be monitored in accordance to the sub-group of the system applied showing a sequential development. Translating this theoretical model into the model of learning and neural plasticity, certain parallels emerge, attempting to explain the processes of plasticity. An abstract structure such as music intervention as system appeals to the general functions contributing to neuro-plasticity in ways of slowly constructing a sequential network. To clarify this model, one can imagine a tree; if the roots are not grounded, the stem cannot develop to support the crown, which carries all the leaves. This shows, that by systematically approach ASD’s with music intervention, the contribution to neural and synaptic connection development has to be constructed from the bottom up. As stated in Chapter 1.2, individuals with ASD find themselves in a world moving ‘too fast’ [22], which calls for the bottom-up and systematic approach described here to show an effect. These rules however, are not strictly understood yet and therefore does the analogy of brain plasticity based on an abstract music intervention system seem as the closest to explain the processes of learning and plasticity induced by ‘music’. Nonetheless, this model does contribute to a re-definition of the theory of executive dysfunction; deconstructing its comprehension and re-constructing it in light of a systemised intervention. This allows the question, if we are looking at executive dysfunctions or dysfunctioning executive functions in autism spectrum disorders; two fundamentally different variations of a theme.

The SCERTS model in the context of music intervention as system The SCERTS (‘SC’ = social, ‘ER’ = emotion regulation, ‘TS’ = transactional) model is an transactional, Family-centered approach to enhance communication and socio-emotional abilities in children with autism [41] The key element of this model is to give possible as well as ongoing therapies a checklist of aspects, which should be adhered to in order to serve as successful intervention. SCERTS uses three main pillars - social communication, emotional regulation and transactional support to confirm this success (for full details of the SCERTS model, refer to [41]). This model has been used across different music therapy goals by Walworth, Register and Engel [44]. Their analysis of music therapists and their goal direction with clients on the autistic spectrum

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revealed that music therapist mostly address interpersonal support and learning for interpersonal support, which makes priority goal 3 of the SCERTS model. Social communication and emotional regulation goals, were addressed, yet not to its full extend [44]. This raises the question in how far does the above already used music therapy models cover the main pathological behaviours of ASD in its fullest? They certainly are addressing the social, communicational and emotional skills, but are they fully suitable at baseline? The here proposed hypothesis of consecutive music systems, addresses this issue by using the full potential of a heterogeneous and complex phenomenon such as music on a as complex pathology. To give full support of this paradigm shift [45] from isolated interventions to a full spectrum of uses of music as intervention, applying this hypothesis will give more insight into its validity through the SCERTS model assessment tool.

Re-defining the executive dysfunction theory in light of music intervention as system Establishing music intervention systems based around the collection, participation and general interaction with this stimulus and a possible SCERTS evaluation, poses a new question; what are the effects of this sort of intervention and how can they be measured? As mentioned above are executive functions crucial to our everyday lives and regulate functions such as planning, working memory, attention, problem solving, verbal reasoning, inhibition, mental flexibility, multi-tasking, initiation and monitoring of actions [5–7], are mainly executed through the frontal lobes. Having systemised music intervention, the application of a theory of executive dysfunction in ASD does no longer suffice. As is seen in the vast amount of literature on the positive effects of music interventions, effects range from general cognitive improvement to changes in social interactions [5,27,30,33,56,57,58,61]; the later as being only one of the major problems in individuals on the autistic spectrum. These improvements are thus seen in brain areas directly connected to executive functions and can therefore not be dysfunctioning. But what does this exactly mean? Posing a theory of executive dysfunction presupposes that these EF’s are not fully functional, i.e. dysfunctional. In other words they simply do not work as they should in individuals on the autistic spectrum. Even though this seems difficult to believe in light of literature showing effect on executive functioning, the expression – to call it that way – still remains unrevised. Therefore we suggest a new ‘expression’ to these non-functional cognitive tasks; the dysfunction of executive function. A small change as it may seem, however directly comparing these two ‘expressions’, a fundamental one. There is a big difference in understanding a cognitive task as completely dysfunctioning, or give a more precise definition of (1) the task itself (here: executive functions) and (2) describing the difficulty within this task. By defining the so-called executive dysfunction theory therefore as a dysfunction of executive functions, leaves the space for the improvement of these. In addition it moves away from a global understanding of not working or badly working cognitive tasks, allowing for a thorough and detailed analysis of the working or improving of cognitive tasks. Some would accuse the author of nit-picking in this context and rightly so. However, it takes a thinking experiment like this, to see the fundamental differences in diction, meaning and implication. At this point it is important to note, that this requested change of terminology is not based on a linguistic thought experiment, as one might assume, but on the ever changing picture of autism and the autistic brain. Therefore assuming that EF are not at all present, are as we know an out-dated concept among todays ther-

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apists, medical staff and researchers [65] and therefore also needs an update in terminology.

Discussion Music intervention as system; laying the ground stone for their development Shouting for a new diction, based on an innovative approach to music intervention would appear as pre-mature. Nonetheless, this crying out loud is an important step for the future of music intervention and autism research; empirically and/or theoretically. By systemising musical intervention – placing on an implicational playground – one can use the ground rules surrounding it to reproduce and reapply these in an experimental setting. Systemising music intervention therefore, changes the general approach of practitioners, using ‘their’ own way of applying intervention to the client. It creates the context in which results move away from single case studies, but can be placed around a central point of assessment creating thoroughness and reproducibility. In this light, the advance to move towards different stages within the global process of music intervention as system is a step into the right direction. Consequently, a consecutive system such as the above proposed (encompassing collectible, mechanical, numerical, natural, motor and social music systems) addresses all nuances, which can be applied in the interventional setting. Therefore, these can be seen within a framework of constant change of not only our understanding of the condition, but more so of the effects the intervention creates. It is the comprehension of the theoretical structure of the proposed intervention systems. If taking the idea that ‘music’ is more than only listening and playing as presented in this paper, one creates another level of valuable cognitive engagement. This stays within the realm of music as shown through the collectible and mechanical system. Additionally, the following step is to engage the participant through her/his own interest of different abstract entities such as numbers and translate these into an analytical interaction. This creates an interaction with the individual interest, the stimulus and enhances the intervention and its effects. Building on these roots and assessing its merits in light of the given theories encompassing and attempting to explain ASD, one is forced to expand on the understanding of these. Taking two of these – the Empathising–Systemising theory and its extension to the extreme mail brain theory [19] and the theory of executive dysfunction [14], argues against the following steps in the here proposed consecutive systematic approach to musical intervention. As defined in this paper, the natural as well as motoric music intervention system is based on the faculties of neural plasticity and neural activation of brain areas involved in music perception and production. These areas overlap with dysfunctioning areas in ASD. Nonetheless are individuals on the spectrum capable to indulge and participate in and with music regardless of gender or age. This relationship of hyper-indulging into a stimulus was hypothesised by Markram and Markram [15] in their ‘intense world theory’. Musical brain activation involves the here-argued executive functions in the prefrontal cortices together with deeper lying structures such as the Thalamus and the brainstem and even the basal ganglia and cerebellum [60]. The direct link of Purkinje and thalamic nuclei regulating inhibition in conjunction to musical perception and possibly the initiation of movement [48] are therefore an important step in the analyses of music on individuals with ASD. Of note are thus the direct effects, music has on individuals on the spectrum linking neural processes involved in both perception

and processing [5,15,27,30,33,56–58,61]. How can therefore the Empathising-Systemising/extreme male brain Theory account for these effect, while only arguing a fundamental, however seemingly limiting approach to a complex condition such as ASD? Focusing on gender differences within the spectrum, does therefore only account for a small part of the condition and lacks a direct transition to intervention development or clinical approaches. Linking the theory of executive dysfunction to this statement, changes therefore also the understanding of how this theory is presented. As mentioned, it is not the theory that lack revision, but the terminology flagging it. Assuming -as given by the name dysfunction – executive functions are simply not working or insufficiently working in individuals with autism, misleads its meaning, while clinical trials have shown the opposite [27]. It is therefore not the question of do they function or not, but their difference to neurotypical executive functions? The music intervention system proposed here therefore aims at answering this question. From music we know that the here mentioned cognitive skills do improve on different levels in both neurotypicals as well as in ASD, the question of how, still remains. Additionally, there is a point of critique to the proposed interventional system, which has to be taken into consideration. Even though it is based on consecutive building blocks, it presupposes a general interest and an innate interaction with music. But how can this system be used, if the participants are not at all interested in any aspect of the above mentioned music based intervention systems? Placing it in a wider context might be an answer, by taking away the aspect of music. However, can this be achieved, by abstracting away from one building block, on which the whole system is constructed? More research into the human perception and processing of multisensory stimuli therefore holds the answer [48]. If multisensory inputs, trigger the above discussed ur-structures of the brain, the presupposition of these structures implying an innate interaction with these stimuli answers the question regardless of the stimulus. Therefore it will not be important, if music is aesthetically appreciated by the participant, but induces states of mind, which act as calming or enhancing [71]. Therefore, seeking to understand the effect of music intervention on the neural development and more importantly the improvement of quality of life in ASD is a question of systematic and individualised stimulation. This is regardless of the actual stimulus. Nonetheless, music does show the strongest benefits on individuals with ASD and therefore remains the prime candidate in alternative and non-invasive improvement of quality of life. Future direction therefore should aim at active integration of music intervention as system as proposed in this paper. Understanding that thalamic modulations are related to task demands rather than multisensory interplay per se – nonetheless contributing to mental-flexibility and attention tasks – makes music intervention a multi-level approach to cognitive development. Placing this in light of the modularity [72,73] and resource sharing [74] hypotheses4 in relation to music intervention in autism will further strengthen our understanding of the effects of music intervention on the whole autistic spectrum. Thus contribute to the improvement of quality of life through a systematic approach of music as multisensory stimulus and intervention.

4 Peretz’s and Patel’s hypotheses are interlinked and can be divided into two stages; stage 1) resource sharing and stage 2) modularity in the event of sound perception and processing. Here the thalamus serves as crucial link between both theories (please refer to Jaschke [75], Controlled Freedom: Cognitive Economy versus Hierarchical Organisation, for full description).

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