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Journal of Music Therapy, XX(XX), 2019, 1–28
doi:10.1093/jmt/thz008
© the American Music Therapy Association 2019. All rights reserved.
For permissions, please e-mail: [email protected]

Assessing the Impact of Music Therapy

on Sensory Gating and Attention in
Children With Autism: A Pilot and
Feasibility Study
A. Blythe LaGasse, PhD, MT-BC
Colorado State University School of Music, Theatre and Dance

Rachel C.B. Manning, MS, OTR/L

Colorado State University Department of Occupational Therapy

Jewel E. Crasta, PhD, OT

Colorado State University Department of Occupational Therapy
Present address: Kennedy Krieger Institute, Baltimore, MD 21205

William J. Gavin, PhD

Colorado State University Department of Molecular, Cellular &
Integrative Neurosciences

Patricia L. Davies, PhD, OTR/L, FAOTA

Colorado State University Department of Occupational Therapy
Colorado State University Department of Molecular, Cellular &
Integrative Neurosciences

Children with autism spectrum disorder (ASD) frequently demonstrate

atypical processing of sensory information and deficits in attentional
abilities. These deficits may impact social and academic functioning.
Although music therapy has been used to address sensory and at-
tentional needs, there are no studies including physiologic indicators

We would like to thank the members of Brainwaves Research lab who assisted with
data collection. This project was funded in part by the Colorado State University
College of Health and Human Sciences to PLD, BL, and WJG. This manuscript was
submitted for peer-review and publication consideration prior to the first authors’
appointment as Editor-in-Chief (EIC) for the journal. As such, the outgoing EIC
handled this manuscript, and Dr. LaGasse had no access to information related to
the review and publication decision process.
Address correspondence concerning this article to Blythe LaGasse, Colorado
State University, 1778 Campus Delivery, Fort Collins, CO 80523. Phone: 970-491-
4042. E-mail: [email protected]
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2 Journal of Music Therapy

of sensory processing to determine the impact of music therapy. The

objective of this study was to determine the feasibility of conducting
study protocols, determine the adequacy of electroencephalography
(EEG) and behavioral measures in identifying attentional differences in
children with ASD compared with typically developing (TD) children,
and to gather preliminary evidence of intervention effects on brain re-
sponses and attention outcomes. Seven children with high functioning
ASD ages 5 –12 and seven age- and gender-matched TD completed
procedures measuring brain responses (EEG) and behaviors (the Test
of Everyday Attention for Children). Children with ASD then com-
pleted a 35-min individual music therapy attention protocol delivered
by a board-certified music therapist ten times over 5 weeks. Children
with ASD completed measures of brain responses and behavior post-
intervention to determine pre- to post-test differences. Consent and
completion rates were 100% for children who met the study criteria.
Feasibility measures indicated that measures of brain responsivity
could be used to determine attentional differences between children
with ASD and typical children. Initial outcome data for brain responses
and behavior indicated positive trends for the impact of music therapy
on selective attention skills.
Keywords:  autism spectrum disorder, attention, electroencephalog-
raphy, music therapy, sensory processing

Sensory processing is integral to an individual’s ability to attend

and respond to the environment. Many children with autism spec-
trum disorder (ASD) exhibit differences in sensory processing
and attentional skills that impact daily functioning (Bundy, Shia,
Long, & Miller, 2007; Christakou et al., 2013; Corbett, Constantine,
Hendren, Rocke, & Ozonoff, 2009; Miller, Lane, Cermak, Osten,
& Anzalone, 2005). The diagnostic criteria for ASD include differ-
ences in sensory processing, in particular hyper- or hypo-reactivity
to sensory input (American Psychiatric Association, 2013). As
early as 1943, researchers indicated that children with ASD have
different reactions to sensory stimuli when compared to typically
developing peers (Baker et  al., 2008; Iarocci & McDonald, 2006;
Tomchek et  al., 2015). Unusual reactions to sensory input are
among the earliest recognizable features of ASD and often are
witnessed before a child has received an official diagnosis of ASD
(Iarocci & McDonald, 2006). Sensory processing and attention
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Vol. XX, No. XX 3

abilities often interact, directly impacting a child’s ability to sustain

engagement in play, social, and academic activities (Liss, Saulnier,
Fein, & Kinsbourne, 2006; Tomchek et al., 2015; Waterhouse, Fein,
& Modahl, 1996). The purpose of this study was to establish feasi-
bility and preliminary efficacy of an individualized music therapy
attention protocol to improve sensory processing and attention
skills in children with ASD.
Sensory processing may be defined as the adaptive responses
(i.e., behaviors) to sensory experiences, i.e., visual, auditory, pro-
prioceptive, or vestibular stimuli (Baker, Lane, Angley, & Young,
2008). As a result, sensory processing difficulties may manifest as
adaptive behaviors that interfere with daily living activities and
communication (Tomchek et  al., 2015). Liss et  al. (2006) used
cluster analysis to examine the function of sensory processing.
The researchers found that hyper-responsivity to sensory stimuli
was correlated with perseverative behavior, over-focused atten-
tion, and exceptional memory; whereas hypo-responsivity was cor-
related with poor social skills and communication impairments.
These differences in sensory processing, including both hypo-
and hyper-reactive responses, were related to the symptomology
of ASD.
When considered from a neural processing lens, sensory
processing may be defined as changes in the activity of neurons in
the brain when receiving input from sensory receptors. Researchers
have used electroencephalographic (EEG) brain imaging tech-
niques to study sensory processing in the cortex. Various tasks or
paradigms are used to examine sensory processing. The particular
EEG paradigm of interest for this study, the sensory gating para-
digm, measures a neural mechanism of sensory processing that
determines one’s ability to filter irrelevant sensory information
(Davies, Chang, & Gavin, 2009; Freeman et al., 1987; Rosburg et al.,
2009). The sensory gating paradigm measures a passive response to
repeated or irrelevant stimuli that is both neurophysiological and
protective, allowing the brain to allocate vital processing resources
to attend to stimuli that are more important (Davies et al., 2009).
When responses to sensory gating are impaired, the brain may be
processing irrelevant or redundant stimuli while failing to capture
sensory input that should be more salient. This processing differ-
ence may lead to perceptual or attentional deficits.
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4 Journal of Music Therapy

Sensory gating may be considered a mechanism of attention, in

that one must selectively attend to specific stimuli while ignoring
irrelevant information (Freedman et al., 1987). If one is unable to
organize sensory input, or filter irrelevant information, attending
to the task at hand becomes difficult (Ayres, 1972). Conversely, if
one is to be able to attend appropriately to a task, one must be
able to adapt to the demands of the environment. This environ-
mental adaptation requires the ability to regulate one’s states of
arousal, which can be hindered if an individual is hypo- or hyper-
responsive to sensory stimuli. The concept of arousal, or alertness,
is one system that plays a role in attention (Peterson & Posner,
2012). Researchers have shown that individuals with ASD have spe-
cific difficulties with these aspects of attention, including orienting
attention, selective attention, and filtering out irrelevant sensory
stimuli (Pasiali, LaGasse, & Penn, 2014; Ravizza, Solomon, Ivry,
& Carter, 2013). These attention difficulties, measured using be-
havioral assessments, impact a child’s ability to play, interact with
others, and learn in the classroom where there may be competing
stimuli within the environment. Thus, future studies using EEG to
measure sensory gating abilities may elucidate neural mechanisms
underlying the behavioral manifestation of poor attention.
In previous studies comparing the EEG of children with sen-
sory processing difficulties and children with ASD to typically
developing (TD) children, researchers have found reduced sen-
sory gating abilities in children with ASD, specifically in their ability
to filter out redundant auditory information (Crasta, LaGasse,
Davies, & Gavin, 2016; Davies et  al., 2009). Furthermore, signifi-
cant correlations were found between sensory gating event-related
potentials (ERP, a brain response to an event, in this case an audi-
tory stimulus measured by EEG) and parent report of child sen-
sory processing behaviors (Crasta et al., 2016; Davies et al., 2009).
Conversely, Kemner, Oranje, Verbaten, and van Engeland (2002)
compared gating in 12 children with ASD to 11 TD children and
discovered no significant differences between groups for sensory
gating. Orekhova et  al. (2008) found different results in sensory
gating based on the level of ASD, where severely impacted chil-
dren demonstrated significantly reduced gating compared with
TD peers. These findings indicate mixed results regarding whether
children with ASD have deficits in sensory gating compared with
TD children. However, if sensory gating in children with and
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Vol. XX, No. XX 5

without ASD were to be demonstrated as different, then this neuro-

physiological process may have the potential to be an indicator of
treatment impact.
Researchers have demonstrated that music is engaging to chil-
dren with ASD (Kim, Wigram, & Gold, 2009), with the sugges-
tion that active music-making can help build attentional skills
(Pasiali et al., 2014). Pasiali et al. (2014) found that children with
neurodevelopmental disorders, including ASD, improved selective
attention, and attentional control after 6 weeks of group music
therapy intervention. Although initial evidence supports the use
of music therapy for improving attentional skills in children with
ASD, there are no known studies investigating the impact of an
individualized music therapy protocol on sensory gating and at-
tentional abilities in children with ASD. Therefore, the purpose
of this study was to establish feasibility and preliminary efficacy of
an individualized music therapy attention protocol to improve sen-
sory gating and attention skills in children with ASD. The aims for
this study were to (a) determine the feasibility of conducting study
protocols including measures of sensory gating, attention behav-
iors, and a 5-week music therapy intervention, (b) determine the
adequacy of brain and behavioral measures in identifying atten-
tional differences in children with ASD, and (c) gather preliminary
evidence of intervention effects on sensory gating and attention
outcomes. We further sought to develop recommendations for fu-
ture research. Research questions related to feasibility were:
1. What percentage of participants will complete EEG and be-
havioral evaluation sessions?
2. What percentage of planned music therapy intervention

sessions will children with ASD complete?
3. Will EEG and behavioral tests demonstrate adequate differ-
ences in baseline measures of attention in children with ASD
compared with TD children to warrant future studies?
4. Will there be a relationship between EEG components and
the Test of Everyday Attention for Children (TEA-Ch) scores?
Research questions related to potential benefits were:
1. Do sensory gating abilities in children with ASD change after
5 weeks of the music therapy attention protocol?
2. Will attention abilities in children with ASD change after 5
weeks of the music therapy attention protocol?
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6 Journal of Music Therapy

Method
Participants
We recruited eight children with a clinical diagnosis of high
functioning ASD for this study. One child did not meet the in-
clusion criteria and was excluded from the study. Of the seven
children who met the inclusion criteria, ages ranged from 5 to
12 (M = 8.42; SD = 2.93; 6 males and 1 female). Participants were
required to have normal or corrected vision and hearing and
speak English as a primary language. Diagnoses that excluded in-
dividuals from participating in this study were: Down syndrome;
cerebral palsy; history of significant brain injury; epilepsy; schizo-
phrenia; bipolar disorder; and depression. Individuals with
these disorders were excluded in order to decrease the potential
of different neurological processing due to another disability.
Furthermore, we included data from seven age- and gender-
matched TD children, using frequency matching where the dis-
tributions of age and sex were similar in the two groups. The TD
children completed baseline measures to be used as a comparison
group (M = 8.28; SD = 1.74; 6 males and 1 female). The TD chil-
dren were a subset of a larger study that examined maturation of
sensory gating (Davies et al., 2009). We included TD children in
order to test research feasibility question 3 regarding differences
between TD children and children with ASD. We offered compen-
sation in the form of a commemorative T-shirt or mug, an option
for a $15 cash gift and $25 cash to offset travel costs. We obtained
Institutional Review Board (IRB) approval of procedures from the
Colorado State University IRB.

Procedure
We conducted a single-group pretest–posttest design to col-
lect initial data on the music therapy intervention for children
with ASD. Pretest and posttest measures included neural sensory
processing measures (EEG) and behavioral responses (TEA-Ch).
The behavioral and EEG testing procedures were completed by
faculty and research assistants in the Brainwaves Research Lab,
from the Occupational Therapy Department and Molecular,
Cellular and Integrative Neurosciences Program at Colorado State
University departments at Colorado State University (fourth and
fifth authors). Participants were involved in two pre-intervention
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Vol. XX, No. XX 7

(i.e., baseline condition) and two post-intervention testing visits,

each lasting approximately 2  h. During these visits the child (1)
participated in a passive listening activity while the EEG sensory
gating data were collected and (2) completed behavioral testing.
Following parental consent and child assent procedures, we
briefed the participant about the EEG recording process and re-
search assistants applied the EEG stretch cap with metal sensors
that record EEG through a water-based gel that conducts brain
signals from the scalp to the sensors. After appropriate conduct-
ance levels were achieved, we provided strategies to the children
to minimize movements and eye-blinks that may cause artifacts
in the recordings. Research assistants fitted the child with in-ear
headphones. The hearing threshold was assessed with a 3-ms click
stimulus. During the EEG recording session, the child watched
Wallace and Gromit, a silent Claymation video, to maintain a calm,
quiet demeanor while passively listening to two auditory paradigms,
each lasting about 20 min separated by a 3-min break. During the
second visit, the participant completed another EEG recording ses-
sion and then completed the TEA-Ch. We used two parallel ver-
sions of the TEA-Ch for the test/retest to avoid practice effects.
Within 2 weeks of the baseline data collection, each partici-
pant with ASD returned to participate in 10 bi-weekly individual
music therapy sessions that occurred over 5 consecutive weeks.
Each music therapy session lasted for 35  min and focused on a
music therapy attention protocol designed and implemented by
the first author. Music therapy sessions were held in the Colorado
State University music therapy clinic. Parents were present in all
music therapy sessions, although they were not participatory. One
graduate research assistant provided support in each music therapy
session. Upon completion of 10 music therapy sessions, the partici-
pant returned to the Brainwaves Research Lab for two additional
testing sessions using the same paradigms as the initial two visits.
Measures
Feasibility. Process assessment data collected included the
number of participants who consented/assented to study proced-
ures and ability of participants to complete evaluation and inter-
vention sessions and reasons for refusal or incompletion. We re-
corded anecdotal data regarding the appropriateness of inclusion/
exclusion criteria for the measures (fifth author) and the music
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8 Journal of Music Therapy

therapy intervention (first author). We also kept anecdotal data re-

garding participant understanding of research protocols.
Sensory gating paradigm used during EEG recording. The sen-
sory gating paradigm used in this study measures a neural mech-
anism that determines the brain’s ability to filter (i.e., gate out)
repeated auditory stimuli (Boutros & Belger, 1999; Davies, Chang,
& Gavin, 2009; Davies & Gavin, 2007). During the sensory gating
paradigm, participants heard 100 pairs of click stimuli separated by
a short period, an interstimulus interval of 500 ms, with the pairs
separated by a long 8-s intertrial interval. The first click represents
the conditioning click, while the second click represents the test
click. The second click is presenting redundant auditory informa-
tion; therefore, a brain with satisfactory sensory gating abilities
should devote fewer resources to this stimulus demonstrated by
smaller brain responses. Each click was 3 ms in duration, presented
at 85 dB SPL (decibels sound pressure level) administered in both
ears through the ER-3A inserted earphones (Etymotic Research)
using E-Prime Software (Psychological Software Tools, Pittsburgh,
PA, USA).
EEG data acquisition. The fourth and fifth authors obtained EEG
recordings using a BioSemi ActiveTwo EEG Acquisition system. EEG
was recorded from 32 Ag–AgCl sintered electrodes based on the
American Electroencephalographic Society nomenclature guide-
lines (1994) with two electrodes, namely the common mode sense
(CMS) and the driven right leg (DRL), used to generate a common
reference voltage (http://www.biosemi.com/faq/cms&drl.htm).
Electrodes were also placed on left and right earlobes, left and right
outer canthus of the eye, and the left supraorbital and infra-orbital
regions in order to collect electrooculograms (EOGs). EOGs re-
corded eye movements, eye blinks, and facial muscle movement
artifacts that were later removed from the data. Data were sampled
at a rate of 1024 Hz.
Scoring event-related potential (ERP) components. The EEG
data were segmented into stimulus-locked segments and averaged
to create an ERP separately for conditioning click (first click) and
test click (second click). The most relevant components of the
ERP to sensory gating are the P50 and N100 peaks (Rosburg et al.,
2009). The P50 component is the first major peak in the auditory
evoked ERP, referring to the most positive amplitude that occurs
around 50 ms, within a window of 40–90 ms, after stimulus onset
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Vol. XX, No. XX 9

(Freedman et al., 1987). The N100 component refers to the most

negative amplitude that occurs around 100 ms, within a window of
90–120 ms, after stimulus onset. The P50 component is thought to
be correlated to stimulus filtering, whereas the N100 component
is thought to be linked to passive attention switching (Davies et al.,
2009; Kisley, Noecker, & Guinther, 2004).
Attenuation of the amplitude of the test click compared with the
conditioning click represents sensory gating. Sensory gating was
evaluated using a difference score obtained by calculating the dif-
ference between peak-to-peak amplitude components between the
first click and the second click for both the P50 and the N100. For
the P50, a positive peak, a larger positive difference score indicates
successful gating, whereas a smaller difference score indicates im-
paired gating. For the N100, a negative deflection, a larger nega-
tive score indicates successful gating, whereas a smaller negative
score indicates impaired gating.
TEA-Ch. The TEA-Ch is an assessment tool with nine subtests
that assess selective attention, sustained attention, and attentional
control/switching through the use of game-like tasks that pre-
sent auditory and visual demands (Manly, Robertson, Anderson,
& Nimmo-Smith, 1999). The TEA-Ch is a standardized test with
acceptable reliability and validity (Manly et al., 1999; Manly et al.,
2001) that has been used successfully to study attention in children
with autism (e.g., Pasiali et al., 2014). This assessment requires ap-
proximately 1 h to complete and has two versions to allow for ac-
curate test–retest for each individual. The test–retest reliability co-
efficients for the subtests range from 0.57 to 0.87.
Subtests of the TEA-Ch that measure sustained attention include
(1) Score!: A  10-item measure that presents 9–15 identical tones
separated by intervals of variable duration. Children are asked to
count the tones without counting on fingers. (2) Score DT: This
measure is similar to Score!, presenting tones and requiring chil-
dren to count in the same manner. However, this measure includes
a distractor of a taped news broadcast, with the additional de-
mand that the child must identify an animal mentioned during the
broadcast. (3) Code Transmission: This task requires children to
listen to a string of digits, presented with 2-s intervals, identify the
occurrence of a target sequence, and then report the digit that im-
mediately preceded the target sequence. This task is considered an
auditory vigilance task. (4) Walk Don’t Walk: This subtest presents
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10 Journal of Music Therapy

“go” and “no-go” tones that correspond with a visual game board
with a 14-square path. When a “go” tone is heard, the child must
mark a square on the path of the game board. When the child
hears a “no-go” tone, no play may be made. (5) Sky Search DT: This
subtest requires children to complete Sky Search while simultan-
eously counting the tones presented as an auditory counting task.
Selective attention is measured by the TEA-Ch through two
subtests, including (1) Sky Search: This task requires children
to identify target items when presented with a laminated sheet
depicting rows of paired images of spacecraft. There are 20 target
images among 108 distractor images. Children are scored on both
speed and accuracy. A motor control version of the task is also ad-
ministered, presenting only target items with no distractor items,
in order to determine the baseline of motor control for the partici-
pant. (2) Map Mission: This subtest presents children with a city
map that contains eighty visual target images among various dis-
tractor images. Children must accurately circle the target images.
TEA-Ch subtests that measure switching/attentional control in-
clude (1) Creature Counting: Children are given a stimulus booklet
that depicts creatures in their burrows, with arrows interspersed be-
tween the creatures. Children are required to count the creatures
from the top-down, then to use these directional arrows as cues
to change the direction of their count. (2) Opposite Worlds: This
subtest uses two types of game boards that feature paths consisting
of numerals 1 and 2. In the “same world” game board, the child is
instructed to verbally state 1’s and 2’s as they appear on the game
board. On the “opposite world” game board, the child is instructed
to verbally say “2” when a “1” is encountered, and verbally say “1”
when a “2” is encountered.

Music Therapy Intervention

The first author of this study, a board-certified music ther-
apist, designed and implemented all the music therapy attention
(MTA) protocol. The MTA protocol involved ten 35-min individual
sessions over a period of 5 weeks. The music therapist developed
the protocol from a neurodevelopmental framework, with the
intention of targeting neural networks involved in attention pro-
cesses. During the sessions, the music therapist used music-based
activities targeting the development of attention skills, with a focus
on selective and switching/attentional control. Selective attention
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Vol. XX, No. XX 11

exercises included playing instruments while ignoring distractor

stimuli and producing a specific rhythm in response to an em-
bedded musical sequence. Switching/attention control exercises
included playing instruments to different melodic and rhythmic
themes and switching instruments or movements to different me-
lodic stimuli, maintaining playing while monitoring additional
stimuli (i.e., playing a sequence part on a xylophone while moni-
toring other parts played by the music therapist), and switching
the rules of a task (i.e., matching a high or low drums played by the
interventionist, then playing the tone opposite to the one played
by the music therapist). Detailed examples of musical activities are
shown in Table 1.
The music therapist used music appropriate for the child’s
age and cognitive level to maintain active engagement and focus
throughout the MTA protocol. The MTA protocol started with
basic exercises in each area of attention and gradually became
more difficult as the children progressed. Although the same ex-
ercises were used across all children, the difficulty level and instru-
mentation were adjusted in order to ensure engagement and a
right-fit challenge.

Data Analysis
Feasibility Measures. The authors of this study reviewed all anec-
dotal notes regarding consent rate, attendance, and participation
in the EEG testing, behavioral testing, and music therapy interven-
tion sessions. Furthermore, the authors recorded potential barriers
to delivering the testing and the intervention. The completion
rate was considered by calculating the number of persons who at-
tended sessions fully, without removal or refusing to engage and/
or follow instructions. This number was converted to a percentage
by dividing the number of children who completed all sessions by
the number of total participants, then multiplying by 100.
Feasibility regarding whether attention differences in children
with high functioning ASD would be evidenced on the EEG sen-
sory gating protocols and the TEA-Ch was assessed using data from
the children with ASD and a comparison group of age- and gender-
matched TD children. Scores recorded in the EEG paradigms were
compared with scores on the TEA-Ch for children with ASD and
TD children to determine whether there was a relationship be-
tween sensory gating and behavioral attention scores.
 Table 1. 12

Example Music Therapy Exercises for Selective and Switching Attention 

Music Therapy
Exercise Example 1 Example 2

Selective The music therapy assistant (MTA) played simple rhythms The MT played a melody on the piano and instructed
attention on a drum, changing rhythms every eight counts. The the child to play a xylophone. When the MT played
child was asked to match the rhythms while playing a particular cue embedded in the melody (for
on an identical drum. Once the child was successful, example, dotted eight, eighth, eighth on do me
a competing stimulus was introduced by the music do), the child would play a drum each time they
therapist. The competing stimulus would begin with a heard the cue. The MT would initially play the cue
distractor instrument (such as a wood block) played at in a different range; however, it would increase the
drastically different rhythms. As the child gained success difficulty by playing the cue in the same range as
ignoring the distractor, the MT would increase difficulty the rest of the melody or by playing the cue with less
with instruments that were similar in timbre to the drum emphasis.
or by playing rhythms closer to what the child was playing.
Executive The MT would play different musical melodies or cues on a The MT and the child were seated facing one another
control/ piano, pairing each with a different instrument that was each with a high-pitched tubano and low-pitched
Switching placed in front of the child. For example, the MT would play tubano. The child copied the rhythms and the
Attention a 5-note melody in a major key with staccato notes, upon pitch of the drum played by the MT. Once the child
which the child would play a wood block. The MT would demonstrated success, the MTA would play a cue
then switch to a lower register on the keyboard, playing upon which the child would play the “opposite”
minor melody with legato notes, to which the child would pitched instrument than the instrument played by
play the finger cymbals. Once the child showed the ability the MT (playing the higher pitched tubano when the
to pair 4–5 musical sequences to instruments, the MT would music therapist played the lower pitched tubano).
begin switching between the different melodies in different Upon hearing the cue again, the child would switch
orders and the child will change their instrument to match back to playing the same pitch as the music therapist.
the melodic pattern. The music therapist increased the Upon success, the MTA would hold a blocking board
difficulty of the exercise by using melodic patterns that were between the child and the MT, preventing them from
Journal of Music Therapy

more similar in nature or in the same range. using their vision in the exercise.

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Vol. XX, No. XX 13

Preliminary Efficacy
EEG Reduction and Analysis. Raw data collected from the
EEG recording session was processed using Brain Vision Analyzer
(second, third, and fourth authors), with data analysis focusing
on recordings from the Cz electrode site located at the crown of
the head at the center of the midline. While electrical noise was
minimized by recording EEG data in a sound attenuated, electro-
magnetically shielded booth, some electrical noise can still appear
and must be addressed before ERPs are averaged. This noise was
removed from the EEG data by referencing channels generated
from an average of the two earlobe sensors that monitor the elec-
trical noise in the environment. Averaged ERP waveforms for each
of the two click stimuli were then obtained as follows. Segments
were created according to when auditory stimuli are presented.
In preparing for scoring the P50 data, the EEG signal was filtered
with a bandpass setting of 10–200 Hz (24 dB/octave) and then seg-
mented into epochs representing either the conditioning or test
click with a duration of 100 ms pre-stimulus onset to 200 ms post-
stimulus onset. Next, artifacts and electrical noise were removed
from the data by deleting segments with deviations greater than
±100  μV on any of the EEG channels or the bipolar EOG chan-
nels. Researchers commonly delete segments of data that contain
artifacts in order to prevent contamination of EEG data that re-
flects actual evoked brain potential in response to the presented
stimulus. The nonrejected segments were baseline corrected and
then averaged to create averaged ERP waveforms for both the con-
ditioning and test clicks in order to measure the P50 component
for each participant. Data related to the N100 component were
processed similarly to the P50 component with the following ex-
ceptions: (a) EEG signals were digitally filtered using a 0.23–30 Hz
bandpass and (b) EEG signals were segmented into epochs with
durations consisting of 200  ms before the click stimulus onset
through 500 ms post-stimulus.
The averaged ERP data were then imported into a computer
program for automated peak picking. This software has been de-
signed specifically for the Brainwaves Research Lab. P50 and N100
peaks were determined by the computer program, and then visual
inspection was used to confirm that correct peaks were selected
based on the morphology of the waveform. The P50 component
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14 Journal of Music Therapy

was measured as the most positive amplitude between 40 and

80 ms. The N100 component was measured as the maximum nega-
tivity between 70 and 150  ms from stimulus onset. Peak-to-peak
amplitude for the P50 component was determined by calculating
the difference between the P50 amplitude and the preceding nega-
tivity. Peak-to-peak amplitude for the N100 component was deter-
mined by calculating the difference between the N100 amplitude
and the preceding positivity. The P50 and N100 peak-to-peak amp-
litudes were used to calculate the sensory gating difference score.

Statistical Analysis
Statistical analysis was conducted using the Statistical Package
for Social Sciences (SPSS). Parametric statistics are reported for
this small sample (ASD: n = 7, TD: n = 7) because all data were nor-
mally distributed (using Shapiro–Wilk test) and displayed homo-
geneity of variance (using Levene statistic). To determine whether
brain and behavioral measures were sensitive enough to demon-
strate differences in sensory processing and attention between chil-
dren with and without ASD with a low probability of occurrence
due to chance, an independent t-test (two-tailed) was performed
comparing the different components of attention in EEG (P50 and
N100) and TEA-Ch scores. To determine whether there was a rela-
tionship between brain and behavioral scores, a Pearson’s correl-
ational analysis was used to compare the difference scores of P50
and N100 components to scores on the TEA-Ch for children with
ASD (preintervention) and TD children to determine whether
there is a relationship between these variables for either group.
A Pearson’s r was also used to determine the correlation between
difference scores of the P50 and N100 components and TEA-Ch
postintervention scores of children with ASD.
To determine whether there was a promising difference in sen-
sory gating abilities pre- and postintervention, a paired t-test (two-
tailed) was performed comparing P50 difference scores and N100
difference scores for pre- and post-intervention data. To deter-
mine whether there was a difference in behavioral testing pre- and
post-intervention, paired t-tests were performed comparing total
TEA-Ch scores and domains scores from children with ASD pre-
and post-intervention. To examine the TEA-Ch scores in the ASD
group pre- and post-intervention, we were interested in change
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Vol. XX, No. XX 15

in performance; thus we used raw scores, which are more appro-

priate than scaled scores, to show change over time (Davies &
Gavin, 1999).
In analyzing results using small sample sizes, significance testing
may not be reliable and p values may be misleading. Effect sizes
allow calculating the effect of the independent variable on the de-
pendent variable. Effect sizes for t-tests were determined by calcu-
lating Cohen’s d. Cohen (1988) defines d  =  0.2 as a small effect,
d = 0.5 as a medium effect, d = 0.8 as a large effect, and d = 1.30 as
a very large effect size.

Results
Feasibility
Completion Rate and Barriers. We screened eight children
for eligibility; of which, one was excluded due to a lack of expres-
sive language abilities. We obtained parental and child consent
for seven individuals who met eligibility requirements. All seven
individuals completed all testing and music therapy intervention
sessions, for a completion rate of 100%. Potential barriers to com-
pletion included long testing times (eight total hours) and a com-
mitment to 5 weeks of twice-weekly therapy sessions. To decrease
the potential for attrition in testing due to long testing times, we
provided breaks, ensured there was one research assistant con-
sistently attending to the child’s needs (while others managed
research equipment), and made efforts to provide clear explan-
ations of all procedures. Furthermore, the individuals testing the
children on the brain and behavioral measures were highly experi-
enced in such assessments for children with ASD. Potential barriers
to music therapy intervention sessions were primarily scheduling.
To meet the needs of the families, evening and weekend sessions
were offered. Children were overall highly participatory in the
music therapy sessions; however, several of the children expressed
a preference for certain activities over others. The music therapist
used the order of session activities and a right-fit challenge to help
maintain interest and completion of the MTA protocol.
Measures of Sensory Gating at Baseline Comparisons.
Descriptive statistics are reported for the P50 and N100 ampli-
tudes for children with ASD and TD children at baseline (Table 2).
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16 Journal of Music Therapy

Table 2.
Comparison of P50 and N100 Amplitudes for Conditioning and Test Clicks

TD Children Pre Music Therapy Post Music Therapy

(n = 7) ASD (n = 7) ASD (n = 7)

P50 amplitudes M (SD) M (SD) M (SD)

Conditioning click 4.52 (1.25) 2.29 (1.37) 1.88 (0.66)
  Test click 3.47 (1.43) 2.40 (1.42) 2.34 (1.12)
N100 amplitudes (n = 7) (n = 7) (n = 5)
  Conditioning click −6.03 (2.15) −2.57 (1.93) −4.75 (2.74)
  Test click −3.04 (1.17) −3.65 (0.94) −2.82 (2.05)

Note. M = mean; SD = standard deviation.

When compared with the grand-averaged ERP of the TD group

(Figure 1a), the grand-averaged ERP of the ASD group (Figure 1b)
had smaller amplitudes for the P50 and N100 components for the
conditioning click, suggesting less robust neural responses. For the
test click (where smaller amplitudes are expected), children with
ASD had a smaller amplitude for the P50 component compared
with TD children; however, larger mean amplitude compared with
their own conditioning click. Children with ASD had larger amp-
litudes on the test click for the N100 component compared with
typical children, and larger amplitudes compared with their own
conditioning click, suggesting less robust sensory gating.
An independent-samples t-test was conducted to compare P50
and N100 difference scores in children with ASD pre-music therapy
and TD peers (Table 3). Means and standard deviations (SD) of
the P50 difference scores for both the groups are shown in Table 3.
There was no significant group difference in P50 difference scores
(t(12) =1.76, p= .10, d = −0.94). Group means suggest that children
with ASD have less robust gating than the TD group. There was a
significant group difference in N100 scores (t(12) = −4.47, p = .001,
d = 2.39), suggesting that children with ASD have significantly less
robust gating at the N100 component compared with TD peers.
Measures of Attention at Baseline Comparisons. Independent
t-tests were conducted to compare scaled TEA-Ch scores between
these groups (Table 3). Typically developing children demon-
strated higher mean scores for each domain of attention (Table 3),
with significant differences between groups in selective attention
(t(12)  =  3.21, p = .008, d  =  −1.69) and total attention (t(12)  =  2.45,
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Vol. XX, No. XX 17

Figure 1.
Plots of the Grand-averaged ERPs: (a) TD Children at Baseline; (b) Children with
ASD at Baseline Period Before the Intervention; and (c) Children with ASD Post-
intervention. The Solid Line Depicts Brain Response to the Conditioning Click
(Click 1) and the Dashed Line Depicts Brain Response to the Test Click (Click 2).
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18 Journal of Music Therapy

Table 3.
Comparison of Behavioral and Brain Measures Between ASD and TD Groups

Children with ASD TD Children

(n = 7) (n = 7) Results of t-Tests

M (SD) M (SD) t value df p value d

Brain measures
Differences scores
P50 −0.11 (1.67) 1.05 (0.52) 1.76 12 .10 −0.94
N100 0.53 (1.58) −2.98 (1.35) −4.47 12 .001** 2.39
Behavioral measures
TEA-Ch scaled scores
Selective 13.71 (3.68) 19.43 (2.94) 3.21 12 .008** −1.69
Switch/control 13.57 (6.24) 18.00 (2.45) 1.75 12 .12 −0.93
Sustained 30.14 (13.07) 45.57 (9.25) 2.01 12 .067 −1.36
Total attention 57.43 (25.18) 83.00 (11.33) 2.45 12 .039* −1.16

Note. M = mean; SD = standard deviation; d = effect size. 

*p< 0.05. **p< 0.01.

p = 0.039, d = −1.16). No significant group differences were found

in switch/control (t(12) = 1.75, p = .12, d = −0.93) or sustained at-
tention (t(12) = 2.01, p = .67, d = −1.36). Large effect sizes (ranging
from d  =  −0.93 to d  =  −1.69) suggest high practical significance
(Cohen, 1988).
Relationship Between Brain and Behavior Measures. Pearson’s
correlation was conducted to assess the relationships between sen-
sory gating difference scores of the P50 and N100 components and
TEA-Ch scores in children with ASD and TD children (Table 4).
There was a significant negative correlation between N100 differ-
ence scores and selective attention (p = .040) for children with
ASD, while for TD children there was a significant negative cor-
relation between N100 and sustained attention abilities (p = .020)
and a significant negative correlation between N100 and overall
attentional abilities (p = .046). This suggests that better attention
abilities (higher attention scores) are associated with better sen-
sory gating (larger negative difference scores) at the N100 compo-
nent. There were no other significant correlations between N100
difference scores and TEA-Ch scores. A significant positive correl-
ation between P50 difference scores and the sustained attention
scores was found for the ASD group postintervention (p = .042);
however, there were no other significant correlations between P50
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Vol. XX, No. XX 19

Table 4.
Correlations Between P50 and N100 Difference Scores and TEA-Ch Scores for ASD and TD
Groups

TEA-Ch Scores

Selective Switch/Cont. Sustained Total

r p r p r p r p

P50 difference scores

  TD group .25 .59 .24 .52 .58 .17 .60 .15
  ASD group (pre; n = 7)) .42 .35 -.13 .79 .2 .66 .18 .71
  ASD group (post; n = 7) .31 .49 .15 .76 .77* .042* .68 .09
N100 difference scores
  TD group (n = 7) .25 .58 -.68 .095 -.83* .020* -.76* .046*
  ASD group (pre; n = 7) -.78 .040* .25 .59 -.3 .52 -.26 .57
  ASD group (post; n = 5) .23 .67 .11 .83 -.34 .51 -.21 .82

Note. r = Pearson’s correlation coefficient; p = probability. 

*p < .05.

difference scores and TEA-Ch scores for TD children or children

with ASD.

Preliminary Efficacy: Comparing Pre- and Postintervention

in ASD
Sensory Gating. The grand-averaged ERP of the ASD group after
an intervention (Figure 1c) shows more organized brain activity
compared with their brain activity before intervention (Figure 1b).
Paired-samples t-tests were conducted to compare P50 and N100
difference scores in children with ASD pre- and postintervention.
There was no significant difference in the P50 difference scores for
children with ASD pre- and postintervention (t(6)  =  0.52, p  =  .62,
d = .26) (Table 5).
Two participants did not have identifiable N100 peaks when
postmusic therapy ERP components were analyzed; therefore,
their data were excluded (n = 5). There was no significant differ-
ence in the N100 difference scores for children with ASD premusic
therapy and postmusic therapy (t(4) = 1.86, p = 0.13, d = 1.17). The
large effect size (d = 1.17) suggests that larger sample sizes may re-
sult in statistically significant differences.
Attention. Paired-samples t-tests were conducted to compare
TEA-Ch scores in children with ASD pre- and postintervention
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20 Journal of Music Therapy

Table 5.
Comparison of Brain and Behavioral Scores for Children with ASD Pre- and
Post-intervention

Pre-Intervention Post-Intervention Results of t-Tests

M (SD) M (SD) t value df p value d

Brain measures
Difference scores
P50 (n = 7) −0.11 (1.67) −0.46 (0.90) .52 6 .62 0.26
N100 (n = 5) 0.67 (2.26) −2.25 (2.71) 1.86 4 .13 1.17
Behavioral measures
TEA-Ch raw scores (n = 7)
Selective 32.05 (10.87) 43.37 (12.34) −2.96 6 .025* −0.97
Switch/control 54.15 (19.09) 52.91 (19.11) 0.25 6 .81 0.06
Sustained 60.53 (45.53) 91.38 (60.50) −1.21 6 .27 −0.58
Total 146.53 (56.49) 187.65 (71.14) −1.71 6 .14 −0.69

Note. M = mean; SD = standard deviation. 

*p < .05.

(Table 5). In analyzing raw TEA-Ch scores, postintervention mean

scores were higher in selective, sustained, and total attention
(Table 5), and there was a significant difference in selective atten-
tion (t(6) = −2.96, p = .025, d = −0.97). A large effect size (d = −0.97)
suggests high practical significance. This difference suggests that
children with autism had significantly better selective attention
abilities after music therapy intervention.
There were no significant differences in switch/control
(t(6) = 0.25, p = .81, d = .06), sustained (t(6) = −1.21, p = .27, d = −0.58),
or overall attentional abilities (t(6)  =  −1.71, p  =  .14, d  =  −0.69).
Furthermore, there was a small decrease in mean scores for switch/
control postintervention. Moderate effect sizes for sustained
(d = −0.58) and overall (d = −0.69) indicate that larger sample sizes
may results in statistically significant differences.

Discussion
The purpose of this study was to establish feasibility and prelim-
inary efficacy of an individualized music therapy attention protocol
to improve sensory gating and attention skills in children with ASD.
The aims for this pilot study were to (a) determine the feasibility of
conducting study protocols including measures of sensory gating,
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Vol. XX, No. XX 21

attention behaviors, and a 5-week music therapy intervention,

(b) determine the sensitivity of brain and behavioral measures in
identifying attentional differences in children with ASD compared
to TD children, and (c) gather preliminary evidence of interven-
tion effects on sensory gating and attention outcomes. We further
sought to use this pilot study to develop recommendations for pro-
cedures in future research.

Feasibility of the Protocol

Feasibility data indicate that children with high functioning ASD
tolerated both brain and behavioral testing measures, inclusive of a
total of 8 h of testing. Children were provided with breaks, and we
ensured that one research assistant was fully attentive to the child’s
needs, engaging the child in conversation, explaining all protocols,
and offering toys/fidgets during set-up. Children were also shown
a silent movie during the EEG testing, in order to provide a focus
for their attention. The EEG system used in this study requires a
gel-like substance to be used for conductivity between the scalp and
electrodes and all children tolerated the gel. The TEA-Ch assess-
ment takes over an hour to complete and children were engaged in
these “games” by a research team member. It should be noted that
we specifically targeted children with high functioning ASD and
the study procedures may not be acceptable for some individuals
who have more severe symptoms.
All children completed the music therapy intervention, indicating
that study protocols were acceptable to individuals who met the in-
clusion criteria. Although some children indicated a clear prefer-
ence for some of the music therapy activities over others, the nature
of an individualized protocol allowed the interventionist to ensure
engagement and a right-fit challenge. The youngest child in the
study (5 years old) initially demonstrated difficulty with completing
all activities, asking for breaks between each activity and for a written
schedule. A visual schedule was incorporated for this child (listing
the activities that would be completed) and short breaks where he
raced the interventionist down the hall and back. Furthermore, all
participants were provided with short periods of time to explore in-
struments or play in any way they desired as a break from the atten-
tion tasks. Future research on attention protocols should provide
breaks within the protocol and allow for the individuals to explore
musically, in order to maintain engagement.
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22 Journal of Music Therapy

One additional aspect of the attention protocol that should be

considered was the use of a board-certified music therapist and a
graduate music therapy student assistant. Assistants in this study
provided musical cues under the direction of the music therapist.
This ranged from a distractor stimulus to musical cues on a com-
peting instrument (e.g., piano or guitar). Although the protocol
could be completed by one person alone, technology or an assistant
would be needed to provide musical cues or distractor stimuli.

Adequacy of Brain and Behavior Measures

EEG. The results of this study indicated mixed results for using
EEG to identify differences in sensory gating and attention be-
tween children with ASD and TD children. The results indicated
that children with ASD had significantly less robust sensory gating
than TD children at the N100 component, supporting research
by Crasta, LaGasse, Davies, and Gavin (2016), even with the small
sample size in this study. However, our analyses failed to find a sig-
nificant difference between groups for the P50. The nonsignificant
finding for the P50 is consistent with findings from Kemner et al.
(2002), who failed to show a difference in P50 for children with
ASD. Interestingly, children with ASD had smaller responses to
the P50 conditioning click than to the test click both pre- and
postintervention (opposite of what is expected). This discrepancy
could indicate a difference in early attention processes in children
with ASD or could indicate that the sensory gating had not yet ma-
tured in these children; however, more studies are needed to con-
firm these results before conclusive decisions can be made about
the importance of using this specific measure in future studies.
Behavioral Measures. When comparing attention abilities of
children with ASD and TD peers, we found that the TD children
demonstrated greater abilities in every domain measured by the
TEA-Ch, with significantly greater selective and overall attentional
abilities. This result suggests that children with ASD may have
deficits in selective and overall attentional abilities; however, fur-
ther research is needed due to the small sample size and effect size.
Although these results are limited, the TEA-Ch identified group
differences in this study and could be used in a future study.
Relationship Between Measures. In exploring potential correl-
ations between baseline attention abilities and sensory gating in
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Vol. XX, No. XX 23

TD children, we found significant correlations between sustained

and overall attentional abilities and gating at the N100 compo-
nent in TD children. This result suggests that stronger attention
abilities may be related to more robust sensory gating. Children
with ASD had a significant correlation between N100 scores and
preintervention selective attention scores, suggesting that children
with ASD that have better gating of the N100 component demon-
strate better selective attention abilities. These results should be
interpreted cautiously due to the small sample size and a large
number of correlations run on few variables.
We also explored potential correlations between attention abil-
ities and sensory gating postintervention for the ASD group. We
found a significant positive correlation between sustained atten-
tional abilities and gating at the P50 component for this group
postmusic therapy intervention. This is an interesting finding, as
P50 gating is thought by some authors to be pre-attentive, while
others have shown that sensory gating at P50 is reduced when in-
dividuals are instructed to actively attend to auditory stimuli in
paradigm (White & Yee, 1997). Furthermore, children with ASD
showed an atypical gating response in the P50 component, with
increased responses to the test click over the conditioning click.
These results should be interpreted with caution due to the small
sample size and lack of control group. However, researchers could
use this information to inform both brain and behavioral measures
of sensory gating in future studies with larger sample sizes.

Impact of Music Therapy on Sensory Gating

In this study, children with ASD had greater difference scores
at the N100 components postmusic therapy, suggesting improved
sensory gating following the intervention. However, these improve-
ments were not statistically significant. Since there was no control
group, we cannot conclusively state that improvements in the raw
scores are related to music therapy intervention. However, larger
effect sizes and differences within groups were found in relation to
N100 gating.
Analysis of differences scores at the P50 component before and
after music therapy revealed a small effect size. It could be that
P50 gating, as a pre-attentive component of sensory processing, oc-
curs too early in neural gating to be impacted by music therapy
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24 Journal of Music Therapy

interventions. Another possible explanation is that because the

P50 component has a much smaller amplitude than N100 peak
amplitudes, the P50 has a smaller signal-to-noise ratio. Therefore,
we need either more participants to increase statistical power or
more trials per subject to potentially lower measurement error.
There is limited research explicitly linking music to changes in
brain processes. There is a precedence in the literature that music
induces neural plasticity that can be measured through changes in
EEG topography (Habibi et al., 2016; Thaut et al., 2014) and ERP
responses (Putkinen et al., 2014). To our knowledge, this is the first
study to explore the impact of music therapy on sensory processing
using EEG.

Impact of Music Therapy on Behavioral Measures of Attention

Our study showed that children with ASD had significant im-
provements in selective attention following music therapy with a
large effect size (i.e., d = .97) suggesting clinical meaningful results.
Our results also indicated that the improved scores on sustained
attention with a medium effect size (i.e., d  =  .58). This suggests
that music therapy intervention has the potential to improve atten-
tional abilities, especially selective attention, in children with ASD.
Interestingly, switch/control attentional abilities slightly decreased
following music therapy, although the difference was not statistic-
ally significant, and the effect size was very small. This could inform
future studies, indicating that intervention protocol emphasis
should be on selective attention and sustained attention, when
compared with attention switch/control. Another interpretation is
that selective attention is more severely impacted in children with
ASD and the protocol may be more impactful for selective atten-
tion abilities.
Our findings support findings by Pasiali et al. (2014), where nine
adolescent children with ASD who participated in eight sessions
of group music therapy interventions demonstrated significant
improvements on tasks related to selective attention. Pasiali et al.
also showed significant differences in attentional control/switch;
however, they conducted group interventions. It could be possible
that certain components of attention would be better targeted in
different intervention settings where there would be more inter-
action with environmental factors such as distractions. Additional
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Vol. XX, No. XX 25

research would be needed to determine the impact of different

intervention types (individual or group) on attentional abilities in
children with ASD.

Limitations
As this pilot study utilized small sample sizes, there were only a
few statistical tests that were significant. The small sample size was
due to limited funds and timeframe for this project funded through
an internal grant. Although some of the statistical tests were not
significant, most of the effect sizes were large. However, due to the
sample size, the results must be interpreted with caution and are
only intended to inform future studies (see Kraemer et al., 2006).
Another limitation of this study was the age range. Participants
in this study ranged from 5 to 12 years, which represents a large
range of skills and abilities in attention skills. Although an age- and
gender-matched control group was used as a comparison for base-
line measures, age could have impacted the results of this study.
A primary purpose for conducting this feasibility study was to
provide initial data and suggest recommendations for improving
methodology. These findings on their own cannot be generalized
to larger populations. The most appropriate use of these findings
would be to generate hypotheses for a more robust study that util-
izes a larger sample size.

Conclusion
This feasibility and pilot study was the first study using physio-
logical and behavioral measures of sensory gating and attention
in children with ASD. Although researchers have suggested that
music affects attentional networks through the perception of dy-
namic patterns in music (LaGasse & Thaut, 2013), there is limited
research demonstrating the efficacy of music therapy for atten-
tion control and none for brain measures of sensory gating. The
results of this study demonstrate that the testing and intervention
protocols were feasible and demonstrated differences between
children with ASD and TD children for the measures selected for
this pilot study. However, the N100 component appeared to be
more sensitive to differences than the P50 component. The ini-
tial data for the music therapy attention protocol demonstrated
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26 Journal of Music Therapy

an impact on selective attention scores. No significant differences

were found for sustained attention and switch/control attentional
abilities. However, the effect size for sustained attention was large
and could be an important measure in future studies along with
selective attention. These results can inform future studies with
larger sample sizes.

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