Clinical Report: Effective Non-pharmacological Interventions for ASD

This clinical report investigates the effectiveness of non-pharmacological interventions for Autism Spectrum Disorder (ASD) in children. It examines two primary interventions: sensory integration therapy and music therapy, discussing their methodologies, outcomes, and limitations. The report includes a search strategy, PRISMA flow diagram, and detailed discussions of the selected studies, including their strengths and weaknesses. Findings suggest potential benefits of both therapies in improving cognitive function and occupational performance, though further research is needed. The report concludes with recommendations for future interventions and research directions to enhance the well-being of children with ASD. The report also discusses other common medications like serotonin re-uptake inhibitors (SSRIs) including fluoxetine and naltrexone which are approved fro alcohol addictions or for treating depression and anxiety do not work comprehensively over all the individuals. This is the reason why special attention is given over the non-pharmacological intervention in order to effectively treat ASD.

Running head: CLINICAL REPORT
Non-pharmacological interventions effective for Autism Spectrum Disorder
Name of the Student
Name of the University
Author Note

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Executive Summary
Autism Spectrum Disorder (ASD) is a type of developmental disorder that is surfaced during
early age of life. It causes problems in communication skills, interactive skills and is also
manifested in the terms of repeated behaviours. Pharmacological interventions used to treat
autism spectrum disorder leads to the generation of several side effects hence importance is
given over the non-pharmacological intervention. Two non-pharmacological interventions
used for ASD disorder include sensory integration therapy and music therapy. However,
further bespoke behavioural interventions are required to be undertaken in order to improve
the health and well-being of children suffering from ASD.

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Table of Contents
Introduction................................................................................................................................3
Search Strategy...........................................................................................................................4
PRISMA 2009 Flow Diagram (Moher et al., 2009)...................................................................5
Discussion..................................................................................................................................6
Sensory Integration therapy...................................................................................................6
Music Therapy.......................................................................................................................9
Conclusion................................................................................................................................12
Recommendation......................................................................................................................12
References................................................................................................................................14

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Introduction
Autism spectrum disorder (ASD) is defined as a developmental disorder. It affects
behaviour and communication skills. Although autism can be detected at any age, it is
categorised as developmental disorder because the specific symptoms of autism spectrum
disorders mainly surface during first two years of life (Manning-Courtney et al., 2013).
According to the guideline created by the American Psychiatric Association the main
indicators which are used in order to diagnose ASD include difficulty in communication,
interaction skills with other people, repetitive behaviours or restricted interest and exhibiting
other symptoms that hurts the ability of a person to function comprehensively in school, work
or other areas of life (National Institute of Mental Health, 2017). Autism is categorised as
spectrum disorder because there is a huge difference in the type and severity of the disease.
ASD is common in all racial, economic and ethnic groups and it is a lifelong disorder.
However, treatments and services can help to improve the overall ability of an individual to
function normally in different areas of life, both professional and personal (Lauritsen, 2013).
There are only few medicines or pharmacological interventions elucidated so far in
order to effectively handle ASD. FDA (Food and Drug Administration) has only approved
two drugs for treating ASD and these are risperidone and aripiprazole. These drugs mostly
used to reduce the irritability associated with ASD. However, these drugs are associated with
several side-effects especially among the children who are the prime victims of ASD.
Moreover other common medications like serotonin re-uptake inhibitors (SSRIs) including
fluoxetine and naltrexone which are approved fro alcohol addictions or for treating
depression and anxiety do not work comprehensively over all the individuals. This is the
reason why special attention is given over the non-pharmacological intervention in order to

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effectively treat ASD. According to Narzisi et al. (2014), non-pharmacological interventions
are effective in reducing behavioural complications associated with ASD. It also helps in the
overall improvement of the cognitive function of the children with no visible side-effects
inline pharmacological interventions. The following clinical report aims to analyze the
effectives of two non-pharmacological interventions over children with ASD. At the end, the
review will attempt to highlight few recommendations that will further help to streamline the
interventions for ASD.
Search Strategy
The two non-pharmacological interventions selected for this clinical report include
sensory integration therapy and music therapy and target population is children between the
age group of 1 to 15 years.
The search strategy is mainly directed by the search of the articles in electronic
database by the use of specific keywords. The main keywords that were used to the database
search include “sensory integration therapy”, “music therapy”, “autism”, autism spectrum
disorder”, “non-pharmacological intervention”. The electronic databases that were use for the
article search include CENTRAL, EMBASE, Ovid MEDLINE, PsycINFO, CINAHL,
ASSIA, ERIC. The main inclusion criteria include research study published on or before
2013, research study conducted over children with ASD and main exclusion criteria include
research study conducted before 2013 and target group is adult. According to Parahoo (2014),
selecting papers which are published recently helped to increase the authenticity of research.
On the basis of the literature search, 20 articles where highlight of then 10 were eliminated
based on the title selection criteria and review of the abstract. Then from the remaining 10 six
articles were finalised for conducting this clinical report. Finalizations of the six articles were
done based on the outcome of the study and the structure of the study.

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PRISMA Flow Diagram (Moher et al., 2009)
Records identified via search of
database
(n = 20 )
Additional records identified via
other sources (5)
(n = 5 )
Records after the duplicates are removed
(n = 20 )
Records which are
screened
(n = 20 )
Records are excluded
(n = 10 )
Full-text articles which are assessed
for their eligibility
(n = 8 )
Full-text articles which are
excluded, (do not meet
inclusion)
(n = 2 )
Studies included in the
literature review
(n = 6)

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Discussion
Sensory Integration therapy
Sensory integration (SI) was initially developed by A. Jean Ayres. It was developed in
order to study the neurological processing of the sensory information. Sensory integrative
therapy (SIT) widely used to treat intellectually challenged children since 1970s. SI mainly
aims to assist children with sensory processing via exposing ASD children to sensory
stimulation in an ordered and repetitive manner. The logic behind this therapy is over time,
the brain will gradually adapt and will help children to process and simultaneously react to
sensations in an effective way (Schaaf et al., 2014). According to Fazlioğlu and Baran (2008)
SI is effective for children with autism spectrum disorders (ASD) and is regarded as third
most commonly used intervention for ASD. Pfeiffer et al. (2011) conducted a study over
ASD children, undergoing occupational therapy via using SI approach (OT-SI). The study
showed promising gains in SIT approach comparison to the Activity Protocol group.
However, Iwanaga et al. (2014) is of the opinion that although sensory integration therapy
(SIT) has been widely adopted for children with ASD, its overall effectiveness is still
controversial. Numerous studies have highlighted that SIT help in improvements in the
sensory-motor skills, reading skills in children with learning disability and motor planning
(Lang et al., 2012). However, there are no significant studies showing the significance of SIT
in cognition, motor planning and motor function of the children (Iwanaga et al., 2014). Thus
in order to ascertain the effectiveness of the SIT over the cognitive function, verbal skills and
motor abilities of the ASD of children, Iwanaga et al. (2014) conducted a pilot study. They
used Japanese version of the Miller Assessment tool for Preschoolers (JMAP) in order to
detect change in the cognitive function. They mainly selected 20 children with high-
functioning autism spectrum disorder (HFASD) having IQs above 70. Among 20 children,

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eight participated in individual SIT session and twelve participated in group therapy (GT)
like communication training, social skills training, kinetic activities and children-parent play
for 8 to 10 months. The result based on the scale of the JMAP taken both before and after the
integration of the therapy. The statistics showed total score of JMAP and index scores except
for the verbal index have increased significantly among the SIT group. While only the total
scores (JMAP score) have only increased in the GT group. Moreover, SIT group showed
promising improvements in the domain of co-ordination, non-verbal scores and complex
index scores in comparison to the GT group. Thus showing that the SIT is effective in
improving the overall cognitive function of the children with ASD in comparison to over
group based interventions (Iwanaga et al., 2014). The main strength of the study is, the
measurement of the cognitive development is based on the JMAP. According to Nakatsuka et
al. (2013), JMAP is an authentic tool that can be effectively used to judge overall cognitive
improvement. However, the study also has certain limitations. For example, the children who
were selected for the study have IQ high than 70. Iwanaga et al. (2014) are of the opinion that
ASD children with IQ lower than 70 suffer from significantly poor cognitive skills in
comparison to IQ greater than 70. A proper randomised control trail might have made the
study more authentic (Dennis et al., 2009). Another limitation of the study is its sample size
(Button et al., 2013). Only 20 children were selected from the study and Button et al. (2013)
are of the opinion that small sample size increases the scope of biased response. Moreover,
the study is based on the previously collected data which again imposed threat over the
getting biased response (Marshall et al., 2013).
In relation to the sensory processing interventions, Case-Smith, Weaver and Fristad
(2015) conducted a systematic review over children with autism spectrum disorder. The
review was mainly directed towards ascertain the efficacy of the sensory interventions in the
domain of sensory integration therapy and sensory-based interventions over sensory

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processing problems. In this evidence based review, a total of 19 studies were reviewed and
of them 5 examined sensory integration therapy effects and 14 were based on the
interventions of sensory-based. All the selected studies highlighted sensory integration
therapies as clinic-based interventions that employ sensory-rich and children oriented
activities in order to improve the adaptive responses of the child towards sensory experiences.
The analysis of the selected papers highlighted that the sensory-based interventions are
mainly classified as class-room based interventions that employs single-sensory strategies
like therapy balls, weighted vests and its influence on child's state of arousal. Sensory-based
interventions mainly highlighted that they may or may not be effective if they fail to follow
the recommended protocols sensory processing problems. The review also highlighted that
randomised controlled trials showed positive effects for sensory integration therapy when the
sample size was small. At the end, Case-Smith, Weaver and Fristad (2015) concluded that the
more rigorous trails employing manual protocols are required to be reviewed in order to
evaluate its effects over children with ASD. The main strength of the study, it is study plan
that is systematic review approach in order to get a summarised overview of the effectiveness
of the SIT. However, the main limitation of the review is it only reviewed 19 studies and thus
poor sample size reduce the overall strength of the research (Faber & Fonseca, 2014).
Kashefimehr, Kayihan and Huri (2018), examined the effect of SIT on different
aspects of occupational performance of the children with ASD. They selected 3 to 8 year
older SD children. Short Child Occupational Profile (SCOPE) was employed in order to
compare two groups of children in the domain of their sensory performance and occupational
performance, SIT children (n=16) and control group (n=15). The analysis of the results
highlighted significant improvement in all the SCOPE domains and SP domains with an
exception of the emotional reactions and emotional or social responses. Overall their study
highlighted improvement in the occupational performance upon the application of SIT over

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ASD children. The main strength of the study is it conducted statistical analysis in order to
elucidate their results in qualitative format. The main limitation of the study, the study was
not randomized and this may increase the chance of getting biased results (Harris, 2013). A
detailed characteristic of the placebo and the trail group of children was also not mentioned
this further hampered the quality of the study (Charan & Biswas, 2013).
Music Therapy
Music therapy is used as an important non-pharmacological intervention for the
treatment of autism spectrum disorder among the children. The importance of music therapy
is, it helps to stimulate both the hemispheres of the brain and thereby helping to improve the
cognitive function (Thompson, McFerran & Gold, 2014). Kim, Wigram and Gold (2009) are
of the opinion that music encourages communicative behaviour and at the same time
encourage structured interaction with others and thereby helping to improve the
communication difficulty among the children with ASD. Music therapy can be alternatively
be defined as a systematic process of non-pharmacological intervention where the therapists
aims to assist the client in order to promote health via employing musical experiences and
quality relationship that helps to develop dynamic force of chance (Reschke-Hernández,
2011). The central of the music therapy mainly employs free and structured improvisation
like singing songs, listening to live music or pre-recorded music and vocalisation. The
underlying therapy behind the affect of music therapy on the overall improvement of the
verbal skills of the children is defined by Gattino et al. (2011). According to Gattino et al.
(2011), listening to music therapy mainly emphasize an interactive process which encompass
selecting music which is meaningful for the person and then asking the person to reflect on
the experience of music. This helps to promote verbal or communication skills. Silverman
(2008) thus rightly concluded that those with verbal abilities, giving verbal reflection on the
music processed are considered to be an important aspect of music therapy.

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Geretsegger et al. (2014) performed a review with an aim to assess the impact of
music therapy over children with ASD. They conducted the literature search till 2013 July
from databases like CENTRAL, EMBASE, Ovid MEDLINE, PsycINFO, CINAHL, ASSIA,
ERIC. They mainly selected randomised controlled trials (RCTs) and controlled clinical
trains study in order to compare the effectiveness of the music therapy over the ASD
children. The review of the 10 studies highlighted that music therapy can help children with
ASD in the domain of improving their overall skills in the primary outcome area and this
includes social interaction, communication, reciprocity in social-emotional context and
initiating behaviour. The authors also highlighted that music therapy might also proved to be
helpful in enhancing non-verbal communication skills under the context of therapy. In the
secondary outcome area, music therapy helping in the improvement of the social adaptation
skills among the children with ASD and in promoting quality of life and well-being in parent-
child relationships (Geretsegger et al., 2014). The main strength of the study is its
representation and detailed layout article selection based on the inclusion and exclusion
criteria. Shamseer et al. (2015) stated that in case of systematic review, a detailed illustration
of the inclusion and exclusion criteria of the article selection help to increase the overall
quality of the research. However, this systematic review has certain limitation like small
sample size and risk bias. Only two authors were employed for the selection of the research
articles and subsequent shorting of the articles based on the inclusion and exclusion criteria.
According to this might increase the overall rate of the chances of performance bias
(Pannucci & Wilkins, 2010).
In relation to music therapy and its affect on the children with ASD, LaGasse, (2014)
conducted a randomised control trial over 17 children between the age group of 6 to 9 years.
The aim of the study is to examine the effect of music therapy group intervention over the
joint attention, eye gaze and interactive communication between the children with ASD. They

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mainly performed comparative study with music therapy group (MTG) and no-music social
skills group (SSG). The children were asked to participate in ten minutes group session of 50
minutes for over a tenure of 5-week. The analysis of the social responsiveness scale (SRS),
the Autism Treatment Evaluation checklist (ATEC) and video analysis of sessions
highlighted that music therapy is helpful in increasing joint attention. However, there was no
significant difference between the groups on the parameter of initiation of communication,
response to certain questions over verbal skills and social behaviours or withdrawals
(LaGasse, 2014). One of the limitations of the study is, it conducted non-blinded trail.
According to Hróbjartsson et al. (2012), conducting non-blinded trial lead to the generation
of biased results. However, the strength of the study is its qualitative approach and the
inclusion and exclusion criteria selected for sample group selection (Mason, 2010).
Thompson, McFerran and Gold (2014) evaluated the effectiveness of family-centred
music therapy in order to promote social engagement of the children with ASD. They
conducted a randomised control trial over 23 children who are aged between 36 to 60 months
and have severe ASD. Family-based music therapy mainly continued for 16-weeks and the
change in the social engagement was measured via the help of parent-report assessment,
parent interview and overall clinician observation. The analysis of the results highlighted that
family based music therapy help to increase the parent-children interaction and this in turn
help to increase the social interactions at home and community based interaction of the
children. However, the application of music therapy showed no promising increase in the
general social responsiveness and language skills of the children (Thompson, McFerran &
Gold, 2014). Thus the main strength of the study is, it provided preliminary support over the
family-based music therapy and its large sample size (Marshall et al., 2009). However, the
study mainly used interview of the parents in order to ascertain the outcome over the children
and this may lead to the generation of blinding bias (Kim et al., 2013).

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Conclusion
Thus from the above critical analysis of the published articles based on the
pharmacological interventions of SIT, it can be concluded that SIT helps in the improvement
of the cognitive function of the children who have mild to moderate IQ ranging on or above
70. SIT also helped to improve the adaptive responses of the child towards executing the
sensory experiences and occupational performances. Thus overall it can be summarised that
the SIT which is mainly based to improve intellectual disability of the child is very effective
as a non-pharmacological interventions in the domain. Another non-pharmacological
intervention highlighted in this clinical report is music therapy. Critical analysis of the
articles base on music therapy highlighted that music therapy helps children with ASD in the
domain of verbal communication, social-emotional reciprocity and initiating behaviour.
Moreover, studies like systematic review highlighted that music therapy also helps in
improving social adaptation skills and thereby promoting health and well-being among parent
child relationship. The improvement of the parent child relationship is also highlighted in the
family based music therapies which are either procured in group or are given individually.
However, the results of music therapy interventions were contrasting like one study showed
effective in improvement of the social responsiveness while another study showed no
promising increase in the social responsiveness apart from verbal or communication skills.
Thus it can be said that further studies are required to be conducted in order to streamline the
detailed outcome of music therapy and SIT.
Recommendation
In order to improve the overall health and well-being of the children suffering from
ASD, the primary thing that is required to be worked upon is their behavioural problems.
According to Lord and Jones (2013), behavioural interventions are the major source of

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change for children with autism spectrum disorders. Lord and Jones (2013) are of the opinion
that behavioural interventions directed towards specific skills like communication approach,
social interaction skills, behaviour towards others help in achieving better outcomes. Lord
and Jones (2013) also highlighted that the interventions must be personalised as such bespoke
intervention help to extract quality results in comparison to group-based intervention.
Moreover, interventions must be procured by the direct care givers under the controlled
supervision of professional nurse.

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