Ind Psychiatry J. 2023 Jan-Jun; 32(1): 176–186.

Published online 2023 Apr 14. doi: 10.4103/ipj.ipj_190_22

PMCID: PMC10236685

PMID: 37274590

Musical preferences of Indian children with autism spectrum disorder and acceptability of music therapy
by their families: An exploratory study

Lakshmi Sravanti, John Vijay Sagar Kommu, 1 Suma Suswaram, 2 and Arun Singh Yadav 3

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ABSTRACT

Background:

Music therapy has been in use for children with autism spectrum disorder (ASD) since the 1940s.
However, there is limited scientific evidence on its use in the Indian context.

Aim:

The present study aims to explore musical preferences of children with ASD and their caregivers’
acceptability of music as a form of intervention.

Materials and Methods:

It is a cross-sectional study of 120 subjects diagnosed with ASD as per the Diagnostic and Statistical
Manual of Mental Disorders-5 identified by convenience sampling. A semi-structured interview schedule
consisting of 25 objective response questions with multiple choices and 11 open-ended questions
(pertaining to music and the use of music) was used to explore caregivers’/parents’ thoughts and
beliefs. The responses to open-ended questions were collected in narrative mode. A descriptive
approach of content analysis was adopted to analyse the data. The data are presented using descriptive
statistics. Institutional Ethics Committee’s approval was obtained for conducting the study.

Results:
Most of the children liked (89.2%, n = 107) music and responded (88.3%, n = 106) actively (listen
intently/hum or sing or dance along) to music. Most subjects preferred rhythm (65%, n = 78) over
melody (15%, n = 18). While 98.3% (n = 118) of the parents were willing to try music therapy for their
child, 61% of them (n = 72) asked follow-up questions like – ”Is there available data on it?” (n = 12;
10.2%) and “Will it be worth investing our time and efforts on it?” (n = 60; 50.8%).

Conclusion:

Most of the children including those with auditory sensitivity like music and prefer rhythm over melody.
Caregivers possess a positive attitude toward the use of music therapy. However, most of them wish to
clarify the scientific basis of the same.

Keywords: ASD, children, India, musical preferences, music therapy

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by social

communication deficits and repetitive sensory-motor behaviours with impairments in functioning often
continuing into adulthood.[1] Its prevalence is on the rise and management of children with ASD entails
a multidisciplinary approach. There is an increase from 1.8% to 7.1% of all diagnosed developmental
disabilities over a period of 10 years.[2] Music has therapeutic potential[3] that can be put to use in
children with neurodevelopmental disorders.[4] Music therapy has been used as an intervention for
autism since the 1940s.[5] It has been shown to reduce undesirable behaviors and improve verbal
communication and social interaction.[6] Music therapy research has explored its efficacy in multiple
domains of functioning. A meta-analysis suggests medium to large effects of music therapy interventions
for children with ASD.[7] Gold et al. (2004)[8] reported a small effect of short-term music therapy (daily
intervention for one week) on verbal communication skills (SMD = 0.36) and a medium effect on gestural
communication skills (SMD = 0.50) with no significant effects on behavioural problem. Geretsegger et al.
(2022)[9] in their updated review of 26 studies (1,165 participants) reported that music therapy
probably reduces total autism symptom severity (SMD -0.83, 95% confidence interval -1.41 to -0.24; 9
studies, 575 participants; moderate-certainty evidence), enhances the global functioning and improves
the quality of life. However, the team mentioned that there was no clear evidence of a difference in
social interaction, nonverbal communication, and verbal communication immediately postintervention.

Music and language have common neuroanatomical substrates viz. the Broca’s region (inferior frontal
gyrus) and temporoparietal regions (superior temporal gyrus, middle temporal gyrus and angular gyrus).
[10] OPERA hypothesis argues that music training enhances speech processing.[11] Musical training
initiated at an early age has been shown to improve the structural and functional organization of various
areas of the human brain viz, the left anterior hippocampus,[12] Heschl’s gyrus or primary auditory
cortex, planum temporale or secondary auditory cortex, primary motor cortex, planum temporale,
arcuate fasciculus, and intraparietal sulcus.[13] In addition, musicians exhibit enhanced top-down
processing of auditory information[14,15] and more efficient preattentive functions, especially in
response to the sounds of the trained instrument.[15,16] Music therapy can be active, wherein the
interventions involve interactive engagement in the form of playing an instrument and creating music,
or passive, where the clients just listen to music that is played during the session. Literature suggests
that active music therapy reduces sympathetic Autonomic Nervous System activity while passive music
therapy increases it.[17]

There is limited research done in the Indian context. Sharda et al. (2018)[18] compared the
neurobehavioural outcomes of a music intervention to a nonmusic control intervention, in 51 children
aged 6–12 years with autism who were randomized to receive 8–12 weeks of music (n = 26) or nonmusic
intervention (n = 25) and reported improvement in social communication and postintervention
functional brain connectivity. Bharathi et al. (2019)[19] conducted an intervention study in 52 children
aged between 6 and 12 years recruited by convenience sampling and reported the therapeutic benefits
of using music in enhancing social skills. Music is a universal language that is a feature of everyday life. It
communicates emotions and has strong social connotations.[20] Music preferences are determined by a
number of external factors such as age of the individual, personality traits,[20] values, empathy levels,
[21] exposure, peer and family influence, the activities one is engaged in while listening to music and
one’s internal preferences for structure, harmony, rhythm, timbre, or lyrics. India is known for its
cultural diversity, which means that the musical preferences of Indian families may vary widely.
Preferences of families will in turn determine a child’s exposure. Moreover, children with autism may be
sensitive to the affective aspects of music[22] and may show special musical interest[23] and enhanced
pitch memory and discrimination.[24] Therefore, it is essential to understand the musical preferences of
children with autism and prevailing patterns of music use in the Indian context to develop a culturally
relevant music therapy intervention. Moreover, despite the lack of evidence for use of music based on
robust research in the Indian context, music therapy is provided by various organizations and
independent professionals catering to the needs of children with disabilities and or autism in India.[25]
Hence, there is a dire need for scientific research in this area, so that the prevalent practices are aligned
with evidence-based guidelines. The primary objective of this study is to explore the musical preferences
of children with autism in India and the secondary objective is to assess current practices prevalent in
their households and caregivers’ attitude toward music therapy. It will help in assessing the feasibility of
interventions using music and serve as a baseline to develop formal interventions in the future.

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MATERIALS AND METHODS

The study was conducted in the department of child and adolescent psychiatry at National Institute of
Mental Health and Neurosciences (NIMHANS), Bangalore, which is a tertiary care center in India. It is a
cross-sectional study of 120 children diagnosed as having ASD using Diagnostic and Statistical Manual of
Mental Disorders-5 recruited by convenience sampling from both out-patient and in-patient settings.
Every subject’s clinical condition was assessed using INDT-ASD[26] and ISAA[27] and relevant data were
collected using standardized data-abstraction forms created for the purpose of the study. The forms
were designed to collect caregivers’/parents’ reports based on their observations in their home context.
Children with hearing difficulty, visual defects, neurological disorders, or any chronic medical illness
were not included in the study as these conditions may impact the perception and processing of music.
Informed assent from the subject (when applicable, i.e. adolescent participant with adequate
understanding and verbal abilities) and written informed consent from parents were obtained at the
time of recruitment. Adequate space and privacy were provided during the examination. The data were
collected in-person and adequate space and privacy were provided during the parent’s participation.
Institutional Ethics Committee’s approval was obtained for conducting the study.

A semi-structured interview schedule was designed as the study is exploratory in nature. A tool to
extract sociodemographic and clinical data from parents of children with ASD was developed in English
by two researchers (a psychiatrist and a speech-language pathologist) of the team with a background of
more than 35 years of musical training (combined). A focused group discussion was carried out among
peers to establish content validation and an expert in the field provided both content and measurement
validated the tool. A pilot study was conducted with five parents to assess for comprehension and
accuracy of the items. The pilot data did not indicate a need for any further amendments. The final
version of the instrument was translated into Kannada and Hindi languages by bilingual study team
members who spoke Kannada or Hindi along with English. These translated versions were back-
translated to check for accuracy by a team of professional translators.

The primary objective of the study was to understand the musical preferences of children who were
diagnosed with ASDs in the Indian context. The secondary objective was to assess the musical practices
prevalent in their households along with caregivers’ acceptability of therapy that uses music.

The exposure of children and their responses to traditional genres of music including Indian classical
(Carnatic and or Hindustani), folk, devotional (bhajans, carols), film music, and lullabies as these genres
of music are more commonly played within Indian households. We used an objective response question
providing the parents with multiple option and also asked them to mention if the songs had regional
significance or not. We assessed the children’s preference for rhythm and/or melody as these are two of
the most basic components of music.[28] Rhythm involves beats and time. Melody involves notes and
pitch. To analyse rhythm and melody, the parents were asked two questions viz. an objective response
question and an open-ended question to substantiate their answer to the previous question. The final
impression was based on both parent’s account and the clinician’s interpretation (of the parent’s
response to the open-ended question). Furthermore, Indian musical tempo is classified as drut (fast),
madhya (medium), and vilaṃbit (slow), which was also assessed.[29] Finally, music can be either
presented in audio and or audio-video (AV) format; therefore, we assessed their preference for the
delivery format. Specifically, children’s responses to these various aspects of music were evaluated as
either active or passive. In the present study, we define active as listening intently, humming or singing
along and moving, smiling or dancing to the music, and passive response as passive listening or
indifference (both of which do not require efforts or active interaction by the listener with the music
being played).

The semi-structured interview schedule consisted of 25 objective response questions with multiple
choices and 11 open-ended questions (pertaining to music and the use of music) under six sections
(Musical Elements and Genre Preference, Situation Specificity, Response of the Child, Caregiver’s
Musical History, Music as a Therapeutic Intervention, Future Recommendations) to explore
caregivers’/parents’ thoughts and beliefs. The responses to open-ended questions were collected in
narrative mode. A descriptive approach of content analysis was adopted to analyse the data. The results
are presented using descriptive statistics and central tendencies.

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RESULTS

All the findings are based on parental observations in the home context and their responses during the
interviews.

Clinical profile of children: The age of the subjects ranged from 1.5 to 17 (mean-5.7) years. Of the 120
children, 116 (96.7%) had their diagnosis confirmed by using INDT-ASD with a score of more than 70 on
ISAA and four children (3.3%) were 1.5 years old at the time of presentation diagnosed as having ASD
after a detailed clinical evaluation. The male-to-female ratio was 3:1. Sixteen children (13.3%) were
noted to have additional language impairment (receptive and expressive). About 33.3% (n = 40) of the
sample had at least one psychiatric comorbidity and almost 15% (n = 17) had two or more psychiatric
comorbidities. Among the neurodevelopmental disorders, the most common comorbidity was Attention
Deficit Hyperactivity Disorder (ADHD) (n = 37, 30.8%) followed by intellectual disability (n = 24, 20%) and
Tourette syndrome (n = 1, 0.8%). Other psychiatric co-occurrences identified were mood disorder (n = 5,
4.2%), anxiety (n = 3; 2.5%), oppositional defiant disorder (n = 2, 1.7%), sleep disorder (n = 6, 5%), and
encopresis (n = 1, 0.8%). Two (1.7%) of the children had precocious puberty. Many of the children had
socioemotional deprivation and significant screen exposure (83.3%; n = 100). A few of the parents
reported experiencing burnout (n = 20; 16.7%) and parental discord (n = 8.3%) families. Seven children
had preterm birth (5.8%) and three children with a history of delayed birth cry (2.5%). Ten children had a
family history of developmental problems [ASD (n = 6, 5.0%), expressive language disorder (n = 3, 2.5%)
and intellectual disability (n = 1, 0.8%)] in a sibling Table 1 presents the remaining clinicodemographic
profile of the sample.

Table 1

Clinicodemographic profile

Clinicodemographic Parameter Sample characteristics

Mean age (current) 5.7 (SD±3.4) years

Gender Male: n=90 (75.0%); Female: n=30 (25.0%)

Socioeconomic status (based on Modified Kuppuswamy classification)[30] Lower: n=20 (16.7%);

Upper lower: n=44 (36.7%); Lower middle: n=23 (19.2%); Upper middle: n=27 (22.5%); Upper: n=6
(5.0%)

Region (Census of India)[31] Urban: n=91 (75.8%); Rural: n=29 (24.2%)

ReligionHindu: n=95 (79.2%); Islam: n=10 (8.3%); Christianity: n=15 (12.5%)

Mean age at symptom presentation (parent-reported) 1.8 (SD±0.4) years

History of regression Present: n=70 (58.3%); Absent: n=50 (41.7%)

Verbal skills Verbal: n=75 (62.5%); Non-verbal: n=45 (37.5%)

Sensitivity to sounds Present: n=64 (53.3%); Absent: n=56 (46.7%)

Severity (based on ISAA scores) (n=116; excludes the four children categorized as “at risk”) Mild:
n=36 (31.0%); Moderate: n=67 (57.8%); Severe: n=13 (11.2%)

Disability (based on ISAA scores) (n=116; excludes the four children categorized as “at risk”) 50%:
n=12 (10.3%); 60%: n=24 (20.7%); 70%: n=28 (24.1%); 80%: n=34 (29.3%); 90%: n=15 (12.9%); 100%: n=3
(2.6%)

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Musical preference of children: The mean age at which exposure to music began was 1.3 (STD ± 1.3)
years. Most children were reported to show a liking toward music (89.2%, n = 107) and only some were
reported to be indifferent to it (10.8%, n = 13). Few children were reported to prefer instrumental music
(8.3%, n = 10). Most children were reported to respond actively to music (88.3%, n = 106), of whom 18
(15.0%) children listened intently, 25 (20.8%) sang along, 46 (38.3%) hummed, 52 (43.3%) moved or
danced to the tune, and four (3.3%) children tried tapping or drumming on surfaces. About 20% (n = 9)
and 42% (n = 19) of children who were nonverbal were reported to listen intently and hum along,
respectively. About similar percentage of children who were verbal were reported to listen intently
(12%, n = 9) and hum along with music (38%, n = 28). It is interesting to note that 83% (n = 53) of
children with sensitivity to sounds were reported to like listening to music (including loud music – n = 4,
6.0%), while 8% (n = 5) were reported to avoid some specific songs by saying “bandh karo” and 9% (n =
6) were reported to avoid loud music. The parents elaborated on the children’s choices by substantiating
their responses with examples. It should be noted that while most of the songs (60%) mentioned by
them carried regional/cultural significance, others (40%) were trending songs from the popular
Bollywood culture or Pop music that did not carry any regional significance.

Table 2 illustrates musical preferences of children and Table 3 presents prevailing practices in
households.

Table 2

Musical preferences of children

Characteristic of music Preference

Preferred genre Rhymes: n=48 (40%);

Film music: n=46 (38.3%);

Devotional: n=22 (18.3%);

Classical: n=4 (3.3%)

Element of music Rhythm: n=78 (65.0%); Melody: n=18 (15%); Both: n=24 (20.0%)

Tempo Fast: n=53 (44.2%); Medium: n=47 (39.2%): Slow: n-20 (16.6%)

Format Audio format: n=15 (12.5%); AV format: n=66 (55%); Both audio and AV formats: n=39 (32.5%)

Response Active: n=106 (88.3%); Passive: n=14 (11.7%)

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Table 3

Prevailing practices in households

Music practices’ parameter Sample

Duration of exposure per day < 30 min: n=11 (9.2%)

30 min-1 h: n=12 (10.0%)

1-2 h: n=51 (42.5%)

> 2 h: n=46 (38.3%)

Activity-specific Activity-specific: n=79 (65.8%); Nonspecific: n=41 (34.2%)

Eating: n=52 (43.3%); Sleep: n=35 (29.2%); Boredom: n=40 (33.3%)

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Musical preference of caregivers: About 40% (n = 48) of parents like film music, 35% (n = 42) prefer
traditional or folk songs, 20% (n = 24) of the parents like to listen to devotional music, and 5% (n = 6) like
classical music. Regarding their history of music training, 2.5% (n = 3) of secondary caregivers (fathers)
and 1.7% (n = 2) of primary caregivers (mothers) had a history of receiving training in Indian classical
music (vocal or instrumental). It is interesting to note that only 4.2% (n = 5) of the parents reported
receiving suggestions to use music as part of their children’s behavioral therapy from either their
extended family members or health professionals. However, none of these families reported having an
understanding of the benefits of music on child development. While 98.3% (n = 118) of the parents were
willing to try music as a form of intervention for their child with autism, 61% of them (n = 72) asked
follow-up questions, for example, “Is there available data on it?” (n = 12; 10.2%) and “Will it be worth
investing our time and efforts on it?” (n = 60; 50.8%). When we assessed the musical preferences for
therapy, a majority of the parents (n = 84, 70.0%) preferred nursery rhymes, 22 (18.3%) prefer
melodious movie music, five (4.2%) preferred devotional music, and nine families preferred the use of
“anything [that was] child-friendly” without overt preference for a specific genre of music for
therapeutic use.

Developmental gains as noted and reported by caregivers: When we assessed the benefits of music on
child development, a few parents reported observing an improvement in their children’s vocabulary
(learnt one or two new words repeated in the songs; n = 12; 10%). Parents also reported an
improvement in social skills such as making eye contact, exchanging smiles, and copying the caregiver’s
dance movements (imitation) when music was a part of the parent-child interactions (n = 8; 6.7%). Eight
(6.7%) parents reported their children learnt the games that caregivers tried to engage them with when
a song was played in the background, five (4.2%) had a decrease in the frequency of context-specific
anxious behaviours when music was played, and seven (5.8%) reported their children had an
improvement in sleep behaviours when music was used during bedtime. In addition, a few parents also
reported their children’s mood improved (sadness and irritability improved; n = 4; 3.3%), frequency of
restricted and repetitive decreased (n = 2; 1.7%), and a parent reported their child’s attention span
increased transiently (0.8%). On exploring further regarding the improvements mentioned by parents in
the language and social domains, they reported that they were initially context-specific, that is, only
when songs were played; however, over time (an average period of 2-3 months) they noted that they
were generalized to other contexts and parents noted functional use of the newly acquired skills.

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DISCUSSION

Parents of children with a wide age range participated in this survey interview study (1.5 to 17 years; M
= 5.7 years). Children’s gender ratio was 3:1, with a male preponderance corresponding with evidence
from a recent meta-analysis.[32] Literature suggests the rates of comorbid conditions among children
with ASD vary substantially from 9% to 89%,[33] with ADHD as the commonly reported condition.[34]
Correspondingly, in the present study, 48.3% of the children had a comorbid condition and ADHD was
the most common comorbidity (33.3%). Receptive and expressive language impairment is common in
children with autism,[35] with 7%-14% having difficulties in acquiring language skills.[36] In the current
sample, 13.3% were noted to have language impairment (mixed receptive and expressive). Well-
documented evidence from the Western context suggests that individuals with ASD are drawn to music
and have a varied inclination toward instrumental music as well.[37] In our sample, almost 90% of the
children were reported to have a liking toward music and approximately 10% preferred instrumental
music. A majority of the children in the current sample appreciated “rhythm” of the music (65%), a few
reported an inclination toward “melody” (15%), and 20% appreciated both qualities of music. Research
suggests that both rhythmic and melodic perceptions are intact in children with autism,[38] so the
differences could be attributed to individual preferences. There is a need for prospective intervention
studies examining the benefits of the use of rhythm as existing literature suggests positive effects on
interactions[39] and motor rehabilitation.[40]

Children were categorized into two groups viz. nonverbal and verbal for the purpose of this study.
Children with no functional speech were categorized as nonverbal and those who used one or more
words contextually were categorized as verbal. The impression was made based on parent report and
clinical observation. Music has the ability to inspire dance and movement[41] and 43.3% of the children
in our study were reported to move or dance to music. Almost similar proportions (40%) of both verbal
and nonverbal children were reported to hum along with music, but 20% of nonverbal children were
reported to listen to music intently as compared to 12% of verbal children. Minimally or low verbal
children with autism are known to process sounds differently.[42] Studies report a prevalence of
auditory sensitivity ranging from 37% to 69% in individuals with autism.[43,44] In this sample, 53.3% of
the children were reported to have sensitivity to sounds. It is interesting to note that while 17% of the
children with auditory sensitivity were reported to avoid specific songs or loud music, 6% of the children
in this study were reported to appreciate loud music. Findings might suggest that habituation or
repeated exposure to loud sounds could have an improvement in children’s auditory tolerance.[45]
Caregivers reported that 12 (10%) children showed improvement in the language (learnt one or two new
words repeated in the songs), eight (6.7%) children showed improvement in social skills such as making
eye contact, exchanging smiles, and copying caregiver’s dance movements, eight (6.7%) children learnt
the games that were enacted during the songs, five (4.2%) had decreased context-specific anxious
behaviors, seven (5.8%) had improved sleep, and stereotypies of two (1.7%) children reduced
transiently. Music has been reported to help in social bonding to enhance cognitive function
(concentration, alertness) and reduce loneliness.[20] LaGasse (2014) has reported improvement in
nonverbal communication outcomes (eye gaze and joint attention) with music therapy for children with
autism.[46] As per the reports of the caregivers, about 40% of present study subjects had shown
improvements in various domains (range 0.8%-10%) such as language, social skills, cognitive function
(attention, learning games), mood, sleep, and stereotypies.

Our study also reports high rates of socioemotional deprivation and significant screen exposure in 83.3%
(n = 100) of children. This finding is consistent with literature that reports excess screen exposure even
in children aged less than 5 years.[47,48] This could be attributed to the easy availability and
accessibility of digital devices and technology and an increase in the affordability of consumers. We
hypothesize that the high rate of screen exposure could have been a significant factor contributing to
socioemotional deprivation. Our study findings suggest that 87.5% of the children had a preference for
AV (audio-video) format, either exclusively (55%) or in combination with audio-format (32.5%); more
than 80% of children had exposure to music for 1-2 or more hours per day and in more than 40% it was
while feeding the child. These preferences may lead to excess screen exposure or unhealthy
feeding/eating habits. While we report possible beneficial effects of music, one should be cognizant of
the mode and medium of exposure, meet the Indian Academy of Pediatric guidelines on screentime,[49]
and ensure not to inculcate unhealthy exposure to screen or indulge in distracted feeding as they can
impact development adversely.[48]

To the best of our knowledge, this is the first study to elucidate the musical profile and attitudes of
caregivers. About 40% of parents reported liking film music, 20% preferred to listen to devotional music,
and 5% liked classical music. It is noteworthy that the proportions of the preferred genres of children
correspond to parental musical interests. This suggests a possibility of children being exposed to
parental choices of musical genres. However, in our sample, we could not establish if it were the same
parent-child dyads that had similar interests. It is important to note that a majority of the parents who
were willing to try music therapy for their child wanted to know existing evidence for this form of
therapy or the likelihood of potential benefits (61%). These families were explained the limited evidence
based on the Western literature and the need for studies to establish evidence in the Indian context.
They were surprised to know about the possible therapeutic potential of music, however, showed
disappointment in the lack of evidence for its use in the Indian population. This calls for establishing an
evidence base for use of music therapy for children with autism spectrum disorder in the Indian context
and aligning the existing practices with it.

Strengths and Limitations: To the best of our knowledge, this is the first study exploring the musical
preferences of children with an ASD in the Indian context and the attitude of their caregivers toward
music therapy. A relatively large sample was recruited (n = 120); however, it is a cross-sectional study
done on a clinic-based population. Data were collected using data abstraction forms systematically
developed for the purpose of the study, yet the findings are not generalizable. There is a possibility of
recall bias. The data are based on subjective observations of parents and clinician’s impressions that are
not objectively quantifiable. In all cases, parents were the primary caregivers who could give maximum
information regarding the children. However, the responses were brief. Hence, only limited conclusions
could be drawn from the analysis. A formal IQ assessment could not be done owing to the practical
difficulties in gathering all data over a single session in the in-patient and out-patient settings. In
addition, there are no data pertaining to the savant skills of the sample. There is a need to evaluate
these aspects in future studies as the neuropsychological processing of music differs in children
possessing savant skills as compared to the rest.

To conclude, majority of children including those with auditory sensitivity like music. Most of the
children prefer rhythm over melody. Caregivers possess a positive attitude toward the use of music
therapy. However, most of them wish to clarify the scientific basis of the same. This study provides basic
information about children’s and caregivers’ musical preferences and existing practices. Future studies
can confirm the findings by using standardized measurements to quantify outcome measures. Besides,
there is a need to develop culturally sensitive tools for measuring the impact of music and evaluating its
effectiveness by conducting prospective observational studies and randomized controlled trials that can
inform evidence-based practices.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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