J Autism Dev Disord (2013) 43:1298–1307
DOI 10.1007/s10803-012-1672-z
ORIGINAL PAPER
A Pilot Study on the Efficacy of Melodic Based Communication
Therapy for Eliciting Speech in Nonverbal Children with Autism
Givona A. Sandiford • Karen J. Mainess •
Noha S. Daher
Published online: 14 October 2012
Ó Springer Science+Business Media New York 2012
Abstract The purpose of this study was to compare the
efficacy of Melodic Based Communication Therapy
(MBCT) to traditional speech and language therapy for
eliciting speech in nonverbal children with autism. Partic-
ipants were 12 nonverbal children with autism ages 5
through 7 randomly assigned to either treatment group.
Both groups made significant progress after treatment. The
MBCT group progressed significantly in number of verbal
attempts after weeks 1 through 4 and number of correct
words after weeks 1 and 3, while the traditional group
progressed significantly after weeks 4 and 5. No significant
differences in number of verbal attempts or number of
correct words were noted between groups following treat-
ment. A significant number of new words were heard in the
home environment for the MBCT group (p = .04). Par-
ticipants in the MBCT group had more imitative attempts
(p = .03). MBCT appears to be a valid form of interven-
tion for children with autism.
Electronic supplementary material The online version of this
article (doi:10.1007/s10803-012-1672-z) contains supplementary
material, which is available to authorized users.
G. A. Sandiford
K. J. Mainess
N. S. Daher
School of Allied Health Professionals, Loma Linda University,
Loma Linda, CA 92350, USA
K. J. Mainess
e-mail: kmainess@llu.edu
N. S. Daher
e-mail: ndaher@llu.edu
G. A. Sandiford (&)
c/o Karen J. Mainess at LLU SAHP, Communication Sciences
and Disorders Department, Loma Linda, CA 92350, USA
e-mail: silverpenlight@hotmail.com; gsandiford03a@llu.edu
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Keywords Autism
Nonverbal
Children
Efficacy

Treatment
Music
Introduction
According to the Center for Disease Control and Prevention
(2012), the prevalence of autism in the United States of
America is one in 88 children, described as a 23 % increase
since the last report in 2009. With the number of children
with autism on the rise, the number of children with autism
who are nonverbal is also rising. It is estimated that 30–50 %
of children with autism never develop functional speech
(Pickett et al. 2009; Prizant and Wetherby 1993). Further-
more, if a child with autism has not developed verbal speech
by the age of five, it is generally agreed upon that the like-
lihood of him or her acquiring speech or language in the
future is significantly reduced (Charlop and Haymes 1994).
Though some research has indicated that speech and lan-
guage can be acquired after this critical age (Pickett et al.
2009) such evidence is limited in nature and often does not
clearly specify the methods used to promote such late
speech/language acquisition (Pickett et al. 2009).
Despite marked deficits in language development, there
is evidence to support that musical abilities in children with
autism are often preserved (Altgassen et al. 2005; Brenton
et al. 2008; Heaton 2009; Molnar-Szakacs and Heaton
2012; Lai et al. 2012; Oimet et al. 2012). Additionally,
research suggests abnormal interhemispheric asymmetry
occurs in individuals with autism, with relatively lower
than normal activation of the left hemisphere (Flagg et al.
2005; Herbert et al. 2005; Lazarev et al. 2010). Evidence
has long supported the importance of the right hemisphere
of the brain in the processing of melody and rhythm
(Berman 1981; Callan et al. 2006; Hoffman 2008; Lo and
J Autism Dev Disord (2013) 43:1298–1307
Fook-Chong 2004; Mostafa et al. 1989; Ono et al. 2011;
Park et al. 2011; Szirony et al. 2007), while the left
hemisphere of the brain is commonly associated with lan-
guage comprehension and use in the majority of individ-
uals (Callan et al. 2006; Knecht et al. 2000; Pujol et al.
2002). If the right hemisphere in ASD is relatively spared,
it may be the case that right hemisphere functions such as
rhythm and melody can serve as areas of strength and
sources of compensatory activity.
The corpus callosum, which joins both hemispheres and
allows for transfer of information between hemispheres, is
often impaired in children with autism (Gozzi et al. 2012;
Hardan et al. 2009; Keary et al. 2009; Shukla et al. 2010).
However, studies conducted on the corpus callosum indi-
cate that it can be strengthened by exposure to music prior
to the age of seven in typically developing individuals
(Schlaug et al. 1995, 2009). Taking into account the
musical strengths of children with autism (Altgassen et al.
2005; Brenton et al. 2008; Heaton et al. 2008; Heaton
2009; Molnar-Szakacs and Heaton 2012; Lai et al. 2012;
Oimet et al. 2012) as well as the overall benefits of music
on the brain (Schlaug et al. 1995, 2009), it is clear that
further research into music based interventions for treating
individuals with autism is necessary.
Various forms of music therapy have been explored for
children with autism in the past (Accordino et al. 2006;
Finnigan and Starr 2010; Miller and Toca 1979; Starr and
Zenker 1998; Wimpory et al. 1995). However these studies
are often plagued with problems such as an insufficient
sample size rendering findings difficult to generalize to the
population as a whole, poor study design making it difficult
to determine what factors contributed most to the
improvement of the subject, or poor description of therapy
techniques resulting in an inability to reproduce the therapy
in a clinical setting (Finnigan and Starr 2010; Lim 2010;
Miller and Toca 1979; Hoelzley 1993). Additionally, these
studies were often completed on children below the age of
5, an age at which normal language acquisition is still
expected.
One such study tested a variation of melodic intonation
therapy (MIT) on a 3-year-old nonverbal male with autism
(Miller and Toca 1979). The male subject received 1 year
of traditional therapy involving signed and verbal language
with little to no improvement at which time adapted
melodic intonation therapy was attempted. The adapted
melodic intonation therapy made use of signed language as
well as an intoned stimulus. After treatment, the subject
was noted to use trained, imitative and spontaneous intoned
verbal attempts that were observed to generalize to other
settings (Miller and Toca 1979). Despite the success of this
case study, the use of a single subject cannot be generalized
to the greater population, nor can it be determined without
the use of a control group whether the adapted melodic
1299
intonation therapy in and of itself resulted in the increase in
language since other factors such as maturation of the child
and the introduction of traditional therapy prior to the
adapted melodic intonation therapy may have played a role
in eventual language acquisition. It should also be noted
that the subject was under the age of 5, an age at which
acquisition of language is still considered probable.
Another study of a 6-year-old nonverbal female with
autism found that the subject imitated a trombone by
grunting (Hoelzley 1993). The clinician continuously sang
utterances to the subject in tone with the trombone. The
subject moved from grunting to singing words to finally
singing phrases. After a year of treatment the subject was
observed to speak the utterances that had been sung to her
(Hoelzley 1993). Again, use of a single subject does not
allow for generalization of these results to the general
population. Though this study was performed on an older
subject, the lack of a control group makes it difficult to
determine whether other factors such as maturation were
responsible for the improvement.
Another larger study utilized 50 subjects with autism
ages 3–5 (both low and high functioning). Subjects wat-
ched 3 days of music treatment videos, speech treatment
videos, or had no treatment. Improvements were seen in
both the speech and music treatment groups; however, low
functioning individuals had the greatest gains with the
music treatments (Lim 2010). While this study does sup-
port the use of music as a viable source of treatment for
young children with autism, it is unclear whether low
functioning subjects were considered nonverbal. It should
also be noted that the age range of children in this study
was 3–5, which is within the range for which normal
acquisition of verbal speech can still be expected. It can-
not be known from this study whether older subjects who
are nonverbal would have made similar gains, particularly
since the likelihood of acquiring language after the age of
5 is commonly accepted as low (Charlop and Haymes
1994).
Recent literature has addressed the theory of Auditory-
Motor Mapping Training (AMMT), an intervention using
music and rhythm to facilitate speech (Wan et al. 2010a, b,
2011; Wan and Schlaug 2010). In their 2011 proof of
concept study, researchers used a single-subject design to
study six nonverbal children between the ages of 5 and 9.
For the purpose of the study, nonverbal was defined as
having no intelligible words. The clinician introduced a
target high frequency word or phrase by singing while
simultaneously tapping out a matching rhythm and pitch on
a set of tuned drums five times a week over an eight-week
period of time. Researchers found that subjects improved in
their ability to articulate words and phrases over time. This
was noted to generalize to words not trained in therapy
(Wan et al. 2011). While these results are promising and
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continue to indicate the need for more music-based inter-
ventions, lack of a control group makes it difficult to
determine whether a cause-effect relationship exists
between treatment and outcome and whether other factors
such as maturation of the child or the intensity of the
particular intervention played a role in the outcome.
Melodic Based Communication Therapy (MBCT) is a
novel treatment developed by the first author based on
experiences within the field and a review of the literature,
which, in theory, proposes to make use of the presumed
musical strengths of the child with autism in order to
increase verbal output. MBCT differs from other music
therapies such as AAMT in that it utilizes a standard
melody for each target word. Standardization of the melody
is made possible by use of a pre-recorded melody. Each
melody is specific to its target word and differs signifi-
cantly from the other melodies. In addition to a standard
melody for each target word, each step is clearly defined, as
is the reinforcement schedule. Additionally, items used for
reinforcement are highly specific to each child. While
AAMT and other musical therapies often make use of other
instruments such as the trombone or tuned drums, which
can be difficult or expensive to obtain and may require a
high level of musical ability or years of training, MBCT
uses pre-recorded instrumentals to accompany the recorded
melody, allowing the clinician to press ‘‘play’’ on a com-
pact disc player to begin. Additionally, unlike the previ-
ously mentioned therapies, which often, with the exception
of Wan et al. omit rhythm as a component of musical
therapy, pre-recorded melodies are initially accompanied
by rhythmic clapping by the clinician and child. Clapping
has been utilized as a source of rhythm by other researchers
in the past (Kelly 2001; Matsuyama 2005; Olander et al.
2010). Additionally clapping has been found, when com-
pared to other motor tasks, such as sequential finger
movements and grasp release movements, to be a more
significant cortical activator (Kim et al. 2011) as well as a
way of significantly improving the syllable production of
words in children with learning disabilities (Jackson et al.
1997).
Because of the great push for evidence-based practice
(http://www.asha.org/policy), the need to explore whether
Melodic Based Communication Therapy is an effective
form of intervention for nonverbal children with autism
through extensive research is apparent. This is a pilot study
on the efficacy of MBCT. The purpose of this study was to
compare the efficacy of Melodic Based Communication
Therapy (MBCT) to traditional therapy for eliciting speech
in nonverbal children with autism. For the purposes of this
paper, efficacy was assessed by: number of verbal attempts,
number of correct words, number of new words reported by
the parent in the home environment, and number of imi-
tative attempts.
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J Autism Dev Disord (2013) 43:1298–1307
Method
Participants
Permission to conduct this study was obtained from the
Institutional Review Board (IRB) of Loma Linda Univer-
sity (LLU) ensuring appropriate adherence to informed
consent procedures and handling of all research data.
Participants were recruited from the southern California
area using local media/newspapers, letters to paraprofes-
sionals, flyers in local clinics, hospitals, universities,
schools, contacting of local support groups, social networks
and word of mouth. Participants were included in the study
if they had a past diagnosis of autism as well as a clinical
diagnosis of autism based on the Autism Diagnostic
Observational Schedule (ADOS). In addition to a diagnosis
of autism, participants needed to be nonverbal. Nonverbal
was defined as having an expressive vocabulary of no more
than 10 words which were not used on a daily basis and
having no functional speech. Participants also needed to be
between the ages of 5 and 7 years. Individuals were
excluded from the study if they were receiving other lan-
guage or articulation treatments or therapy at the time of
the study, were unable to regularly attend four 45 min
sessions of therapy weekly for 5 weeks, had a history of
severe hearing impairment, had severe visual impairment/
blindness, had a diagnosis of an organic impairment of oral
or laryngeal structures, or had a significant medical illness
or condition which would prevent the child’s participation
in the treatment procedures. These conditions included, but
were not limited to cerebral palsy, paraplegia, spina bifida,
uncontrolled seizures, dysarthria, and amputation of
arm(s). Twelve participants who resided in the Southern
California area were included in the study, 11 males and 1
female. The participants included 5 seven year olds, 3 six
year olds, and 4 five year olds. Per parent report, partici-
pants had all received a minimum of 1 year of speech
therapy prior to entering the study with a range of
1–6 years of therapy depending on the participant. Each
participant had been previously seen by up to four speech
pathologists prior to entering the study. See Table 1 for a
description of the participants’ characteristics.
Measures
The Autism Diagnostic Observation Schedule (ADOS), a
semi-structured, standardized assessment of communica-
tion, social interaction, and play consisting of four mod-
ules was used to verify the diagnosis of autism (Lord et al.
1989, 1999, 2000; Overton et al. 2008). The second
author, a speech language pathologist trained and certified
to administer the ADOS, administered Module 1 to the
study participants with the assistance of graduate students
J Autism Dev Disord (2013) 43:1298–1307
Table 1 Mean ± SD of descriptive data for the participants (N = 12)
Age in years Gender # words reported by parents
5.83 ± 0.8 1 Female 2.3 ± 2.7
(5.0–7.6) 11 Males (0–9)
For ADOS communication score the maximum score is a 10. The higher the child’s score the greater the level of impairment. The cutoff score for
autism is 4. For reciprocal social interaction score, the maximum score is 14. The higher the child’s score the greater the level of impairment. The
autism cut off score is 7. For the combined score the maximum score is 24 and the autism cutoff is 12 (Lord et al. 1989)
in the Communication Sciences and Disorders program at
LLU.
Outcome measures for this study were: number of verbal
attempts, number of correct words, number of words
reported by the parent, and number of imitative attempts. In
order to measure number of verbal attempts and number of
correct words over time, a criterion referenced vocabulary
test developed by the first author for the purposes of this
study was given at baseline and the beginning of each
treatment week. The criterion referenced vocabulary test
was given again at the close of the last treatment week.
Score sheets for baseline and weekly criterion referenced
vocabulary testing were used to document the participants’
responses over time using the International Phonetic
Alphabet (IPA). The criterion referenced vocabulary test
was conducted as follows: the clinician would pull one of
the stimulus items from a bin and ask the participant,
‘‘What is this?’’ The participant’s response was then tran-
scribed verbatim using the International Phonetic Alphabet
(IPA). Clinicians completing the criterion referenced
vocabulary test were not blinded to the type of therapy the
child was receiving, as they were the same clinicians
completing the therapy. Clinicians were however blinded
as to the method used to score criterion referenced testing.
Criterion referenced testing was videotaped and 40 % of
the videos later reviewed at random by the first and second
author separately in order to ensure for accuracy.
The first and second author scored criterion referenced
testing using the following procedures: verbal attempts
which were close approximations to the target word such
as/hæ/for/hænd/were scored as correct words. Verbal
attempts which were nonsensical and bore little resem-
blance to the target word such as/owio/for/hænd/were tal-
lied under verbal attempts. See Appendix D for an example
of the criterion referenced vocabulary testing score sheet
and instructions used by the reviewers.
A parent survey was compiled based on the information
needed for inclusion/exclusion criteria as well as the
information needed for a reinforcer assessment and
assessment of the child’s current vocabulary. The rein-
forcer assessment was a modification of Sturmey’s rein-
forcer assessment (2008), which requires parents to list
possible reinforcers with corresponding examples followed
1301
ADOS (algorithm scores)
Communication Reciprocal social interaction Comm. ? social interaction total
7.8 ± 2 11.4 ± 2 19.3 ± 3.3
(4–10) (7–14) (16–24)
by a list of their child’s top three reinforcers. The parent
survey was also used to tally the number of words reported
by the parent prior to and following the completion of
treatment. Parents were asked to list the words he/she had
heard the child say in the home environment.
Imitative attempts were tallied based on a review of the
video recordings from the first and final treatment sessions.
Any attempt to verbally imitate the clinician was scored as
one imitative attempt. Imitative attempts for the first 10
trials were tallied for every participant’s first and last
session.
Research Design and Procedures
A randomized control design was used in order to determine
the effectiveness of the experimental treatment and control
for external factors such as maturation of the participants and
the intensity of the administered therapy. Upon entering the
study, children were put into three groups according to their
age, and then randomly assigned to one of two treatment
groups. The two groups were: the traditional therapy group,
which represented the standard therapy procedures the par-
ticipant would receive in a private practice setting and the
Melodic Based Communication Therapy (MBCT) group,
which represented the experimental group. Participants who
joined late were randomly assigned to either group (see
Fig. 1 for a flowchart on the movement of participants
through the study). Participants received 5 weeks of inter-
vention, with four 45 min individual sessions a week.
Twenty-five target words were chosen based on high
frequency words children typically use first (Appendix A).
Twenty-five stimulus items were chosen to represent the
target words. Target words and stimulus items were the
same for each group. The goal of therapy for each treat-
ment group was to train the production of the twenty-five
target words. If the twenty-five target words were learned,
then two word utterances incorporating the twenty-five
target words were then trained (e.g. ‘‘kick ball’’).
Clinicians were first year graduate students in the
Communication Sciences and Disorders program at LLU
trained extensively to provide both traditional therapy and
Melodic Based Communication Therapy under the super-
vision of the first and second authors. Treatment
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Fig. 1 Sampling and flow of

Assessed for eligibility
participants through randomized
(n=15)
control rrial
Total including late joiners
(n=17)

Excluded for
Enrollment not meeting
criteria (n=3)

Grouped/Blocked into category by age

then Randomized (n=12) Joined 1 week
late (n=1)

Joined 2 weeks
Allocated to MBCT late (n=1)
Allocated to
group (n=6)
traditional group
Allocation (n=6) Allocated to MBCT Randomly
group after joining
assigned to
late (n=2)
either group
(n=2)

Week 1 (n=5) Week 1 (n=6)

Week 2 (n=5) Week 2 (n=7)
Week 3 (n=5) Week 3 (n=8)
Follow -up Week 4 (n=5)
Week 4 (n=8)
Week 5 (n=5)
Week 5 (n=7)

Total lost to follow Total lost to

up (n=1) follow up (n=1)

Analyzed (n=5) Analyzed Pre/Post measures (n=7)

Excluded (n=1) Excluded from analysis (n=1)
Reason: dropped after 3 Reason: serious illness
days
Analysis Analyzed weekly measures (n=5)
Excluded from weekly analysis due to late
Parent Report (n=3) joining (n=2)
Excluded due to no report
given (n=2) Parent Report (n=5)
Excluded due to no report given (n=2)

procedures for the traditional therapy consisted of using the
child’s three primary reinforcers to train and reward correct
productions as well as attempts to name stimulus items.
See Appendix E for a list of the reinforcers used in this
study. The clinician stated the word clearly while holding
up the stimulus item, then asked the child to repeat the
word after him/her. Acceptable cues were: phonemic cues,
manual manipulation of lips/articulators, visual cues for
placement and verbal instructions about where and how to
use articulators. Therapy progressed from having the child
imitate nouns and verbs to asking the child to indepen-
dently name the items in response to the question: What is
this? If the child was able to name the majority of the
words independently, the procedures were repeated for two
word utterances such as ‘‘kick ball.’’ See Appendix B for a
complete list of procedures used for traditional therapy.
Procedures for MBCT were similar to the traditional
therapy in that the same 25 words and stimulus items were
used. The child’s top three reinforcers were also used to
provide rewards for correct responses and attempts during
therapy. The children were allowed to listen to a CD
recording of the word set to melody while the therapist
presented the stimulus item to the child simultaneously. No
two melodies were the same. Therapy then progressed from
listening to a recording of the word set to melody, to hand
over hand clapping of the rhythm, to unison clapping of the
rhythm, to independent clapping of the rhythm, to inde-
pendent clapping of the rhythm while singing to the
recording with the clinician, to singing with just the cli-
nician while clapping, to singing with just the clinician
without clapping, to singing while the clinician mouthed
the word silently, to singing the word independently, to

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answering the sung question, ‘‘What is this?’’ with the
melodic version of the expected target word, to answering
the spoken question, ‘‘What is this?’’ with the expected
target word. If the child was able to name the majority of
the words independently, then the same procedures were
followed for two word utterances. See Appendix C for a
complete list of instructions used for MBCT.
Results
Data was summarized using descriptive statistics. A two-
way mixed factorial ANOVA (2 groups 9 6 times) was
used to examine changes between the two groups over
time. The outcome measures for the two groups were
compared using the Mann–Whitney U Test at weekly
intervals. Changes in outcome variables over time were
assessed using Wilcoxon Signed Ranks Test. Intraclass
correlation coefficient was used to examine the inter-rater
reliability. Fisher’s exact test was used to compare the
proportions of males/females between the two groups. The
level of significance was set at p \ .05.
Fourteen participants were originally included in the
study; however, one dropped out after a few days and the
other was not readily available for testing due to illness. As
shown in Fig. 1, the traditional group had 5 participants. The
MBCT group had 7 participants. Two participants in the
MBCT group, however, did not receive the full 5 weeks of
therapy due to later enrollment in the study. All participants
received at least 3 weeks of therapy. Ten participants
received 5 weeks of therapy, five participants in the tradi-
tional group and five participants in the MBCT group (see
Fig. 1 for the flow of participants through each stage of the
experiment). No significant differences were found between
the two groups prior to therapy for age, number of verbal
attempts, number of correct words, number of words repor-
ted by the parent, or ADOS scores (see Table 2).
Both treatment groups made significant progress in
number of verbal attempts (F5,40 = 6.9, p \ .001), number
of correct words (F5,40 = 4.1, p = .04), and number of
imitative attempts following treatment (z = -2.5, p = .01).
In the MBCT group number of verbal attempts increased
significantly after week one (z = -2.4, p = .02), week two
(z = -2.0, p = .04), week three (z = -2.0, p = .04), and
week four (z = -2.2, p = .03). The participants in the tra-
ditional group, however, had significant progress in number
of verbal attempts only after week four (z = -2.0, p = .04)
and week five (z = -2.1, p = .04). The difference between
number of verbal attempts expressed by the traditional group
and number of verbal attempts expressed by the MBCT
group at the completion of therapy approached statistical
significance, with the MBCT group displaying more verbal
attempts overall (z = -1.4, p = .08).
1303
For the number of correct words, the participants in the
MBCT group had significant progress after week one (z =
-2.2, p = .03) and week three (z = -2.0, p = .05). For
participants in the traditional group, however, the number of
correct words increased significantly only after week four
(z = -2.0, p = .04) and week five (z = -2.0, p = .04).
There was no significant difference, however, in number of
correct words between the two groups at the completion of
therapy (z = -0.2, p = .40) (see Table 3). Parents reported
a significant improvement in number of new words heard in
the home and other environments for participants in the
MBCT group (z = -2.0, p = .04). On the other hand, there
were no significant changes in the number of new words
heard in the homes of the participants in the traditional group
(z = -1.6, p = .11). When between group comparisons
were made, however, no significant difference was noted
between groups for number of new words heard in the home
environment (z = -.75, p = .45) (see Table 3). For number
of imitative attempts, the participants in the MBCT group
showed significantly greater overall gains than the traditional
group (z = -2.2, p = .03) (see Fig. 2).
Reviewers demonstrated high agreement for all mea-
sures taken. For number of verbal attempts (Intra class
correlation coefficient (ICC) = 0.96, p \ .001), for num-
ber of correct words ((ICC) = 0.71, p \ .001) and for
number of imitations (ICC = 0.96, p \ .001).
Discussion
The aim of this study was to compare the efficacy of
Melodic Based Communication Therapy (MBCT) and
traditional therapy in eliciting speech in nonverbal children
with autism. Efficacy was evaluated by number of verbal
attempts, number of correct words, number of words
reported by the parent in the home environment and
number of imitative attempts. While both therapies were
found to be effective at the completion of the study, results
suggest a possible faster rate of improvement for the
MBCT group as well as greater overall gains in verbal
attempts and imitative attempts.
These findings seem to lend further support to the
positive effects of music-based interventions previously
found by multiple researchers (Finnigan and Starr 2010;
Lim 2010; Miller and Toca 1979; Hoelzley 1993; Wan
et al. 2011). Furthermore, parents within the MBCT group
reported a significant increase in number of both taught and
untaught words in the home environment, lending some
support to other recent findings regarding the generaliza-
tion of skills taught using music to production of words not
taught during therapy (Wan et al. 2011).
The faster rate of improvement for the MBCT group,
greater overall gains in verbal attempts and imitative
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Table 2 Median (min, max) of participant baseline characteristics et al. 2005; Herbert et al. 2005; Lazarev et al. 2010), and
(N = 12) melody and rhythm are housed in the right hemisphere of
Traditional MBCT p value** the brain, as research has indicated, (Berman 1981; Callan
(n = 5) (n = 7) et al. 2006; Hoffman 2008; Lo and Fook-Chong 2004;
Mostafa et al. 1989; Ono et al. 2011; Park et al. 2011;
Male n=5 n=6 0.58***
Szirony et al. 2007) then it may be expected that individ-
Age* 5.8 (.8) 5.9 (.9) 0.93
uals with autism might show an affinity or preference for
Number of verbal attempts 11 (0, 22) 8 (3, 18) 0.75
tasks relating to music and rhythm. This potential affinity
Number of correct words 0 (0, 9) 3 (0, 5) 0.15
for tasks pertaining to music and rhythm may explain the
Number of words reported 5 (0, 8) 8 (0, 10) 0.34
by parent
immediate progress of those in the MBCT group where
Number of words imitated 3 (0, 9) 1 (0, 5) 0.43
melody and rhythmic clapping were employed daily. Fur-
thermore, research indicating an increase in fibers in the
ADOS communication 9 (6, 10) 7 (4, 10) 0.56
score corpus callosum in those exposed to music, potentially
ADOS social interaction 11 (7, 13) 12 (10, 14) 0.16 allowing for better transfer of information between hemi-
score spheres (Schlaug et al. 1995, 2009), may further explain the
ADOS total score 17 (16, 23) 20 (16, 24) 0.56 initial progress for the MBCT group, particularly as the
* Results are reported as mean (SD)
corpus callosum has been cited as an area of impairment in
children with autism (Gozzi et al. 2012; Hardan et al. 2009;
** Mann–Whitney U test
Keary et al. 2009; Shukla et al. 2010).
*** Fisher’s exact test
Although the MBCT group initially showed greater
MBCT melodic based communication therapy
progress, a plateau effect was noted after 4 weeks of
therapy resulting in an overall lack of difference between
Table 3 Median (min, max) differences [Difference = post–pre] treatment groups. The lack of a difference in overall
between groups in verbal attempts, correct words and words reported number of words and number of verbal attempts during
by parents over time by type of therapy for all subjects criterion referenced testing over the full 5-week period may
Traditional MBCT p value** indicate a need for a change in the target words or trained
melodies after a period of 3–4 weeks has passed in order to
Verbal attempts 2 (-1, 16) 12 (7, 22) 0.08
continue the desired result. Further research implementing
Correct words 5 (1, 6) 5 (-1, 22) 0.40
the use of new melodies after this period may be necessary
Words reported by parent 6 (2, 23) 13 (5, 51) 0.45 to examine the full benefits of MBCT. In addition, research
** 2 tailed test; MBCT melodic based communication therapy looking into initial treatment with MBCT followed by the
use of traditional speech and language therapy after week 4
may also be warranted to determine if using MBCT ini-
tially will produce a spike in the therapeutic success of
traditional speech and language therapy when traditional
therapy is used as a secondary treatment.
The finding that the number of verbal attempts in the
MBCT group at the close of treatment increased in a
manner approaching significance when compared to the
traditional group, while number of correct words did not,
was noteworthy. This may imply that melody and rhythm
may also be factors in increasing the number of intentional
non-word attempts a child with autism makes. Previous
research has addressed the importance of shaping such non-
word verbal attempts into words while treating children
Fig. 2 Median number of words imitated pre and post treatment by
type of treatment with autism (Dawson 1989; Newman et al. 2009). The lack
of a difference in number of correct words between groups
attempts as well as the significant improvement in number following treatment, may indicate the need to spend less
of words said in the home environment may have been due time reinforcing for verbal attempts and more time care-
to an increased motivation of the child to complete the fully shaping verbal attempts into actual words (e.g.,/e/ to /
therapeutic tasks when melody and rhythm were imple- be/ to / bed/) as suggested by Newman et al. 2009.
mented. If individuals with autism demonstrate right Both treatment groups showed progress in a population
hemisphere strengths, as multiple studies suggest (Flagg that is often difficult to treat. This may have been due to the

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J Autism Dev Disord (2013) 43:1298–1307
intensity of the treatment and the highly specific nature of
the reinforcers. Reinforcers in general have been shown to
assist in the learning of many behaviors in children with
autism (Koegel et al. 2009, 2010; Sturmey 2008; Volkert
et al. 2008). The importance of intensity of the interven-
tions may warrant further investigation.
Limitations and Future Research
Sample size may have been a limitation of the study. While
studies on children with autism, particularly nonverbal
children, are often small due to inherent difficulties in
recruiting, testing and treating this population, a larger
sample size would have allowed for greater generalization
of outcomes to the population at large and greater power
overall. Seventeen children were assessed for eligibility
overall, however due to the specificity of the inclusion and
exclusion criteria only fourteen were included in the study,
two of whom were lost to follow up.
Lack of follow-up was another limitation of this study.
Although all parents initially provided the number of words
heard at home as well as a list of those words, not all
parents at the close of the study reported this information.
In both groups, 2 parents failed to provide a follow up
report on words heard in the home environment, providing
a smaller sample size for comparison between groups.
Additionally while attempts were made to follow up
with participants a few months after the study to determine
the progress of the child over time via a survey, only 3
participants in the MBCT group responded and none in the
traditional group responded. Due to the limited number of
responses and lack of a response from participants in the
control group no analyses was completed.
While both therapies were shown to work in an intensive
one-on-one, 45 min, 4 days per week setting, research
should be conducted comparing the benefits of MBCT to
that of traditional therapy at a lower intensity level. In
addition, with the rise in the cost of treatment and health-
care for children with autism, (Wang and Leslie 2010)
further research into the effectiveness of using MBCT in
the home environment as conducted by a parent or family
member may be warranted.
While speech therapy is often the norm for children with
autism, little research supports its efficacy for this popu-
lation (Weber and Newmark 2007). Preliminary findings of
this randomized control study suggest that both MBCT and
traditional speech therapy are effective for children with
autism. While results seemed to indicate both therapies
were effective, MBCT appeared to provide more rapid
results as well as greater overall gains in verbal attempts
and imitative attempts. These findings may indicate the
need for additional research into music-based interven-
tions. Should further research continue to support the
1305
benefit of music-based interventions for children with
autism who are nonverbal, there may be a need for speech
language pathologists to implement MBCT and/or other
music based therapies in clinical and public school settings.
Additionally should research continue to support the ben-
efits of music-based interventions for this population, uni-
versities may wish to offer more training in music-based
interventions to students enrolled in their speech pathology
programs.
Acknowledgments Funding from the Communication Sciences and
Disorders and Rehabilitation Sciences Departments at Loma Linda
University supported this research. We are grateful to the families
who participated in this research and to the talented and patient Loma
Linda University Communication Sciences and Disorders graduate
students who were involved in the providing of therapy, Brittany
Masai, Jordan Shimamura, Ryan Forgette, Christine DerDanielian,
Jennifer Diaz, and Cassie Richardson. We also thank the Sachs
Norton Clinic for the use of their speech therapy rooms for the
duration of the study. Special thanks to pediatric neurologist
Dr. Sarah Roddy and neuroscientist Dr. Ernie Schwab for their
invaluable advice on the neurology of the brain as well as their
supportive role in planning and designing this study. Special thanks,
as well, to statistician Dr. Grenith Zimmerman for her invaluable
support in the design and planning phases of this study. Special thanks
to musicians Alan-Pierre Eloi (Alleykat Entertainment Inc.) and
Shannon Hicks, for their role in making MBCT a reality. Special
thanks to the first author’s family and friends for their support and
prayers throughout the duration of this study. God is able.
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