Beeldende therapie

Beeldend therapeuten faciliteren emotionele, sociale, fysieke en creatieve processen in een systematische cyclus van observeren, formuleren van behandeldoelen, behandelen en evaluatie van de voortgang van kinderen. Werken met kunstmaterialen biedt een focus op tactiele en sensorische motorische ervaringen. Een dergelijk proces kan bijdragen aan nieuw gedrag. Het biedt behandelmogelijkheden voor een kind/jongere met ASS dat/die moeite heeft met het waarnemen van eigen gevoelens en ervaringen. Tijdens het maken van kunst kan het kind voorkeuren en nieuwe vaardigheden verkennen en ontwikkelen, en gevoelens en ervaringen verwerken.

Beeldende therapie heeft tot doel reflectie, verandering en persoonlijke groei te bevorderen door het gebruik van kunstmaterialen en in een veilige en faciliterende omgeving. Ook creëert de concreetheid van de visuele en tastbare ervaringen mogelijkheden voor verbalisering en reflectie en generaliseren deze vaardigheden naar thuis en op school (Schweizer et al.,  2020; Snir & Regev, 2013).

Dans- en bewegingstherapie

Dans- en bewegingstherapie is een therapeutische vorm waarbij beweging en dans worden gebruikt als een middel voor psychologische, sociale, cognitieve en fysieke integratie. Het is gebaseerd op het idee dat lichaam en geest onlosmakelijk met elkaar verbonden zijn. Deze benadering heeft voor kinderen en jongeren met autisme als doel om hun expressievermogen te vergroten, zelfbewustzijn te ontwikkelen en sociaal-emotionele vaardigheden te versterken. Uit de Nederlandse en Internationale literatuur is gebleken dat danstherapie bij kinderen met ASS zich naast de beschreven aspecten vooral richt op het bevorderen van non-verbale afstemming en relationele synchronisatie (Koch et al, 2015; Samaritter, 2020; Samaritter & Payne, 2017; Koehne et al, 2016; Manders et al, 2021). Een centrale categorie is daarbij de ritmische synchronisatie en de ruimtelijke synchronisatie, zoals die door spiegelinterventies worden opgeroepen.

Dramatherapie

Dramatherapie is een vorm van therapie die gebruikt maakt van processen uit de drama en/of theater als middel voor therapie. Het doel is om persoonlijke groei, psychologisch herstel en welzijn te bevorderen. De therapeut maakt gebruik van verschillende technieken, zoals rollenspel en improvisatiespel. Deze hebben tot doel om kinderen en jongeren met autisme te helpen om zichzelf beter te begrijpen en nieuwe vaardigheden aan te leren. Voor kinderen en jongeren met autisme kan het een platform bieden om op een gestructureerde manier interacties na te bootsen, emoties te verkennen en sociale vaardigheden op te bouwen.

Muziektherapie

Tijdens muziektherapie worden muzikale interventies gebruikt om individuele doelen binnen een therapeutische relatie te bereiken. Kinderen en jongeren met autisme ervaren vaak moeilijkheden op het gebied van communicatie, sociale interactie en gedragsregulatie. Muziektherapie biedt een uniek platform met als doel om kinderen en jongeren te laten leren en groeien zonder dat traditionele verbale communicatiemethoden nodig zijn. Het maakt gebruik van ritme, melodie en harmonie om connecties te maken die verder gaan dan woorden. Daarnaast heeft deze benadering tot doel om vaardigheden te bevorderen die nodig zijn bij interactie en communicatie, en om kinderen en jongeren te helpen bij het structureren van informatie, niet als een willekeurige opeenstapeling van elementen, maar juist geordend. Belangrijke technieken binnen muziektherapie zijn vrije en gestructureerde improvisatie, en zingen en luisteren naar muziek (Gold, 2006).

Speltherapie

Speltherapie is een behandelvorm die vooral individueel wordt ingezet bij kinderen tussen de vier en twaalf jaar oud (Groothoff, 2009). Het richt zich op het beïnvloeden van het spel van kinderen, om zo problemen in hun ontwikkeling aan te pakken. Spel wordt in deze context gezien als het belangrijkste communicatiemiddel van kinderen. Tijdens speltherapie kan een kind uitbeelden wat het heeft meegemaakt en hoe het dit heeft ervaren. Het spel bevindt zich op de grens tussen verbeelding en werkelijkheid, met als doel dat kinderen zichzelf kunnen ontwikkelen en gevoelens kunnen uiten die ze nog niet verbaal kunnen uiten. Het biedt hen ook de mogelijkheid om spanning te ontladen en nieuwe vormen van gedrag uit te proberen.

Op dit moment is er nog onvoldoende zicht op de evidentie omtrent de effectiviteit van bovenstaande vormen van vaktherapie. De richtlijn werkgroep wil in deze module meer inzicht krijgen in deze kwestie.

1a. Social interaction

1b. Verbal communication

1c. Non-verbal communication

2. Quality of life

3. Flexibility

4. Stereotypy

_{Abbreviations:  ADOS = Autism Diagnostic Observation Scale; ASD= Autism spectrum Disorder; ASSP= Autism Social Skills Profile; CARS = Childhood Autism Rating Scale; CBCL = Child Behavior Checklist; CCC-2 = Children's Communication Checklist; DSM = diagnostic and statistical manual of mental disorders;  ESCS = Early Social Communication Scales;  EQ5D= Euroqol 5D; FQoL = Beach Family Quality of Life; MT= Music therapy;  MBCDI-W&G = MacArthur-Bates Communicative Development Inventories, words and gestures; PDDBI = Pervasive Developmental Disorder Behavior Inventory; PEP = Psychoeducational Profile; PedsQL = Pediatric Quality of Life Inventory; PPVT-4 = Peabody Picture Vocabulary Test-4; RCT = randomized controlled trial; SRS = Social Responsiveness Scale; SSIS = social skills improvement system rating scales; SSRS-P = Social Skills Rating System Scale-Parent form;  TSSA= TRIAD Social Skills Assessment; VABS =Vineland Adaptive Behavior Scales; VPES = Verbal Production Evaluation Scale  VSEECS = Vineland Social Emotional Early Childhood Scales}

_{* Mean age and percentage females are reported for the total study population only}

Results

1. Social communication

The Cochrane review by Geretsegger (2022) assessed social communication in different meta-analyses separated by domain: social interaction (n = 11 studies), verbal communication (n = 8 studies) and non-verbal communication (n = 6 studies). The definitions and instruments used per included study are summarized in Table 2 below. This is followed by the results, which are described and analyzed per separate domain.

Table 2. Definitions for social communication

1a. Social interaction

Eleven studies reported on social interaction. The results were pooled for three different subgroups based on follow-up: effect on social interaction immediately post-intervention, effect on social interaction five months post-intervention and effects on social interaction 11 months post-intervention (Figure 1). The results showed that immediately post intervention (SMD 0.09, 95% CI -0.11 to 0.29, eleven studies, 576 children) there was no difference in social interaction between music therapy and control. Five months post-intervention, an effect in favor of music therapy was found, with an SMD of 0.54 (95% CI -0.11 to 1.19, two studies, 59 children). This was a clinically relevant difference. One study compared the effect of music therapy and control on social interaction eleven months post-intervention and found no clinically relevant difference between treatment arms (SMD -0.06, 95% CI -0.30 to 0.18, 258 children).

Figure 1. Forest plot for social interaction, comparing music therapy to control

1b. Verbal communication

The results for verbal communication were also pooled for two different subgroups based on follow-up (Figure 2). The results showed that immediately post intervention (SMD 0.10, 95% CI -0.22 to 0.43, seven studies, 249 children), there was a no clinically relevant difference in verbal communication between music therapy and control. One study reported on verbal communication five months post-intervention and reported a small difference in favor of Music therapy (SMD 0.22, 95% CI -0.33 to 0.76, 52 children). This was not a clinically relevant difference.

Figure 2. Forest plot for verbal communication, comparing music therapy to control

1c. Non-verbal communication

The results for non-verbal communication were also pooled for measurements immediately post-intervention (Figure 3). There was a small difference found in non-verbal communication between music therapy and control in favor of music therapy, with an SMD 0.15 (95% CI -0.17 to 0.46, six studies, 165 children). This was not a clinically relevant difference.

Figure 3. Forest plot for non-verbal communication, comparing music therapy to control

2. Quality of life

Three studies reported on quality of life. The results of a pooled analysis show that music therapy was associated with better quality of life immediately post-intervention, when compared to the control, with a small effect size favoring music therapy (SMD 0.32, 95% CI 0.04 to 0.60, three studies, 340 children) (Figure 4). This was not a clinically relevant difference. One study also assessed quality of life at eleven months post intervention and found no difference between two groups (SMD 0.04, 95% CI -0.21 to 0.29, 249 children).

Figure 4. Forest plot for quality of life, comparing music therapy to control

3. Flexibility

Four studies reported on flexibility, or as defined in the systematic review ‘adaptive behavior’ measured using the SRS subscale autistic mannerisms, CBCL, ABC and VABS. The results for flexibility were also pooled for different follow-up subgroups (Figure 5). This showed that immediately post-intervention, there was no difference in flexibility when comparing music therapy with placebo (SMD -0.03, 95% CI -0.22 to 0.16, four studies, 432 children). One study reported on the effect of flexibility at five months post-intervention and found a difference in favor of music therapy with an SMD of 0.56 (95% CI -0.12 to 1.24, 35 children). This was a clinically relevant difference. Another study reported on the effect at eleven months post-intervention and found a small difference in flexibility between intervention arms (SMD -0.12 95% CI -0.36 to 0.11, 290 children), with an effect in favor of control. This was not a clinically relevant difference.

Figure 5. Forest plot for flexibility, comparing music therapy to control

4. Stereotypy

The included systematic review did not report on stereotypy.

Level of evidence of the literature

Because the literature review only included RCTs, the level of evidence of all outcomes started at high and was downgraded as below.

1. Social communication

The level of evidence regarding the outcome measure social communication was downgraded as follows:

1.a Social interaction- immediately post intervention: By 2 levels because of study limitations such as inadequate allocation sequencing, inadequate blinding, and inadequate handling of missing data (risk of bias, -1) and because of wide confidence intervals, crossing the border of clinical relevance but also including no effect (imprecision, -1). This results in a low level of evidence.

1.a Social interaction- 5 months post intervention: By 4 levels because of study limitations such as no proper randomization and inadequate blinding (risk of bias, -2), a small study population and because of wide confidence intervals, crossing the border of clinical relevance (imprecision, -2). This results in a very low level of evidence.

1.a Social interaction- 11 months post intervention: By 2 levels because of study limitations such as inadequate blinding (risk of bias, -1), and because of insufficient power (imprecision, -1). This results in a low level of evidence.

1.b Verbal communication - immediately post intervention: By 2 levels, because of study limitations such as inadequate blinding and inadequate handling of missing data (risk of bias, -1), and because of insufficient power (imprecision, -1). This results in a low level of evidence.

1.b Verbal communication - 5 months post intervention: By 4 levels, because of study limitations such as no proper randomization and inadequate blinding (risk of bias, -2), wide confidence intervals, that cross the border of clinical relevance and no effect, and a small study population (imprecision, -2). This results in a very low level of evidence.

1.c Non-verbal communication: By 2 levels, because of study limitations such as insufficient blinding and inadequate handling of missing data (risk of bias, -1), and a small study population (imprecision, -1). This results in a low level of evidence.

2. Quality of life

The level of evidence regarding the outcome measure quality of life was downgraded as follows:

Immediately post-intervention: By 2 levels, because of study limitations such as inadequate blinding (risk of bias, -1) and insufficient power (imprecision, -1). This results in a low level of evidence.

11 months post-intervention: By 2 levels because of study limitations such as inadequate blinding (risk of bias, -1), and insufficient power (imprecision, -1). This results in a low level of evidence

3. Flexibility

The level of evidence regarding the outcome measure flexibility was downgraded as follows:

Immediately post intervention: By 2 levels because of study limitations such as inadequate blinding (risk of bias, -1) and because of insufficient power (imprecision, -1). This results in a low level of evidence.

5 months post intervention: By 3 levels because of study limitations such as inadequate blinding (risk of bias, -1), a small study population and because of wide confidence intervals, crossing the border of clinical relevance (imprecision, -2). This results in a very low level of evidence.

11 months post intervention: By 2 levels because of study limitations such as inadequate blinding (risk of bias, -1), and because of insufficient power (imprecision, -1). This results in a low level of evidence.

4. Stereotypy

The outcome stereotypy has not been graded due to lack of evidence.

A systematic review of the literature was performed to answer the following question:

What is the effectiveness of music therapy, drama therapy, play-based interventions, dance-interventions, or art-interventions when compared to waitlist control or usual care among children with ASD?

Relevant outcome measures

The guideline development group considered social communication and quality of life as crucial outcome measures for decision making and flexibility and stereotypy as important outcome measures for decision making.

A priori, the working group did not define the outcome measures listed above but used the definitions used in the studies.

The working group defined a difference of 25% in the relative risk for dichotomous outcomes and 0.5 SD (or 0.5 SMD) for continuous outcomes as a minimal clinically important difference for all outcome measures.

Search and select (Methods)

The databases Medline and PsycINFO (via OVID) and Embase (via Embase.com) were searched for systematic reviews with relevant search terms from 2018 until 17 August 2023. The detailed search strategy is depicted under the tab Methods. The systematic literature search was a combined search for this module and the module about psychomotor therapy. The systematic literature search resulted in 348 hits. Studies were selected based on the following criteria:

• Systematic reviews (searched in at least two databases, detailed search strategy, risk of bias assessment and results of individual studies available) comparing intervention with waitlist control or usual care in children;
• Full-text English language publication; and
• Studies according to the PICO.

45 studies were initially selected based on title and abstract screening, of which 20 fitted the PICO described above. After reading the full text of those 20 studies, 19 studies were excluded (see the table with reasons for exclusion under the tab Methods), and one study (Geretsegger, 2022), solely regarding music-therapy, was included.

When analyzing studies included in the systematic review by Geretsegger (2022), studies were included in the analysis when:

• Study population was mostly children (at least 80%);
• Full-text English language publication

When outcomes were only assessed during intervention and no post-intervention measurements were taken, studies were excluded for the specific outcome analysis, as this would have little to no implications for daily practice. In some cases, this led to entire studies being excluded.

Results

One systematic review, including 14 relevant RCTs, was included in the analysis of the literature. Important study characteristics and results are summarized in the evidence tables. The assessment of the risk of bias is summarized in the risk of bias tables.