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A Pilot Study on the Effects of Orff-Based Therapeutic Music in Children With

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A Pilot Study on the Effects of Orff-Based Therapeutic Music in Children With Autism Spectrum Disorder
Ladan Dezfoolian, Mina Zarei, Hassan Ashayeri and Majid Yousefi Looyeh
Music and Medicine 2013 5: 162 originally published online 24 June 2013
DOI: 10.1177/1943862113491502

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Article
Music and Medicine
5(3) 162-168
A Pilot Study on the Effects of Orff-Based ª The Author(s) 2013
Reprints and permission:
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Therapeutic Music in Children With Autism DOI: 10.1177/1943862113491502
mmd.sagepub.com
Spectrum Disorder

Ladan Dezfoolian, MSc1, Mina Zarei, MD2,

Hassan Ashayeri, MD3, and Majid Yousefi Looyeh, PhD1

Abstract
Music has been used by therapists to facilitate communicative behaviors and social engagement with individuals with autism
spectrum disorder (ASD). We conducted this study to determine the effectiveness of Orff music therapy on social interaction,
verbal communication, and repetitive behavior of children with autism. Five children with autism who had no previous experience
in music or play therapy were recruited. Social interaction, verbal communication, and repetitive behavior of the participants were
scored pre- and postintervention (Orff music therapy) using Autism Diagnostic Interview–Revised. The mean scores of social
interaction were 26.60 and 14 before and after therapy, respectively (P < .001). The mean scores of verbal communication and
repetitive behavior were reduced significantly (P < .05). The reduction in the scores indicated a good outcome. All participants
improved significantly in their social interaction and verbal communication. The Orff music therapy also helped to decrease their
repetitive behavior. Using Orff music therapy at autistic children’s care centers is encouraged.

Keywords
music therapy, Orff method, autism spectrum disorder, children, Autism Diagnostic Interview–Revised (ADI-R)

Introduction results showed that the participants significantly increased their

pretest to posttest verbal and speech production in both music
Children and adolescents with autism spectrum disorder (ASD)
and speech training groups; however, low-functioning partici-
present with significant limitations in the development of verbal
pants showed a greater improvement after the music training
language and conventional forms of nonverbal communication
than after the speech training.16
such as eye contact, gesture, and body language, with a corre-
There are varying approaches to music therapy in this con-
spondingly limited development of communicative skills.1-4 text. Approaches that have emerged from the field of education
Music has been used by therapists to facilitate communicative
include Orff-Schulwerk, Dalcroze Eurhythmics, and Kodaly.
behaviors and social engagement with these individuals.5-7
Another model that developed directly out of music therapy is
Music therapy also promotes the development of reciprocal,
Nordoff-Robbins.17 Nordoff-Robbins music therapy (NRMT)
interactive communication, and play.8-10
is an improvisation-based approach that Paul Nordoff and Clive
The positive effect of music on language development of
Robbins originally developed in 1959.18 The approach involves
children with ASD in the previous studies was attributed to
the improvisational use of music to evoke responses, develop
increased attention, enjoyment, and optimal social context.11-13
relationships, and address emotional, cognitive, social, and
Gross et al conducted a pilot study on 18 children aged 3.5 to 6 musical goal areas.19 In NRMT, clients take an active role in
years with delayed speech development. Both phonological
capacity and the children’s understanding of speech increased
under treatment as well as their cognitive structures, action pat- 1
Islamic Azad University, Central Tehran Branch, Tehran, Iran
terns, and level of intelligence.14 In 2004, Whipple conducted a 2
Dermatology & Cutaneous Surgery Department, University of Miami Miller
meta-analysis of 9 studies comparing music and no music situa- School of Medicine, Miami, FL, USA
tions in children and adolescents with autism. The results indi- 3
Tehran University of Medical Sciences, Tehran, Iran
cated that all types of music intervention have been effective on
increasing the communicative behaviors including vocaliza- Corresponding Author:
Mina Zarei, Dermatology & Cutaneous Surgery Department, University of
tion, verbalization, gestures, vocabulary comprehension, and Miami Miller School of Medicine, 1600 NW 10th Ave, RMSB 2049A, Miami, FL
echolalia with communicative intention.15 In another study 33136, USA.
conducted by Lim on 50 children (3-5 years old) with ASD, the Email: [email protected]
Dezfoolian et al 163

creating music together with their therapists on a variety of stan- Manual of Mental Disorders (Fourth Edition [DSM-IV]) criteria of
dard and specialized instruments, requiring no special skills or autistic disorder. All of the children’s parents gave informed con-
prior experience to play.18-20 Kim et al21 conducted a rando- sent for their children to be involved in this study. The study has
mized controlled study to investigate the effects of improvisa- been approved by the ethics committee of Tehran’s Islamic Azad
tional music therapy on joint attention behaviors in preschool University, and all the researchers of the study were committed to
children with autism, by comparing with playing session ther- the Declaration of Helsinki. Since this study had no control group,
apy. The results indicated a better effectiveness of improvisa- investigators and patients were not blinded.
tional music therapy on facilitating joint attention behaviors
and nonverbal social communication skills in these children.
Another approach, not often cited in the literature as being
Outcome Measurement
used in this context, is the Orff method also known as Orff- Symptoms of the participants were scored by Autism Diagnos-
Schulwerk (schoolwork) or Music for Children, which is an tic Interview–Revised (ADI-R) before and after the Orff music
approach to music education conceived by the German compo- therapy, and the results were analyzed using paired t test of
ser Carl Orff.22,23 Orff’s approach was based on his belief that SPSS program version 16. The level of significance was .05.
the easiest method of teaching music is to draw out the child’s The data analysis was done by an outside statistician.
inherent affinities for rhythm and melody and allow these to The ADI-R is a structured interview conducted with the par-
develop in natural ways, leading the child by his or her intuition ents of individuals who have been referred for the evaluation of
from primitive to more sophisticated expression.24 The Orff possible ASD and measures behavior in the areas of reciprocal
approach combines music, movement, drama, and speech into social interaction, communication and language, and patterns
lessons that are similar to child’s world of play. It is often of behavior.30,31 The ADI-R has also been used in some other
called ‘‘elemental music making’’ because the materials studies as an outcome measurement.16 The interview is divided
needed to teach are ‘‘simple, basic, natural, and close to a into 5 sections: opening questions, communication questions,
child’s world of thought and fantasy.’’25 social development and play questions, repetitive and restricted
Orff accomplishes this by means of a carefully planned pro- behavior questions, and questions about general behavior prob-
gram, beginning with speech patterns, rhythmic movement, and lems.31 An autism diagnosis is indicated when scores in all 3
2-note tunes and then moving logically into pentatonic mel- behavioral areas exceed the specified minimum cutoff scores
ody.22,24 The generated music is largely improvisational and uses that are 10 for social interaction, 8 for verbal communication
original tonal constructions that build a sense of confidence and and language, 7 for nonverbal communication and language,
interest in the process of creative thinking. Music is chosen with and 3 for restricted and repetitive behaviors. Therefore, reduc-
strong nationalistic flavor, being related to folk songs and music tion in the scores indicated a positive and good outcome.
of the child’s own heritage.26 The emphasis in this methodology is
placed on child-centered, creative, active music making that
allows children to express themselves.26 Orff designed a special
Orff Music Therapy Intervention
group of instruments, including glockenspiels, xylophones, Before the Orff therapeutic music sessions began, a preliminary
metallophones, drums, and other percussion instruments, to fulfill assessment session was held to evaluate how engagement
the requirements of the Schulwerk courses.22 The simplicity of would occur between the therapist and the participant. The ses-
the technique allows all ranges of disabled children to participate sion was considered independently for each child. All children
in the learning process.27 were treated by the same experienced Orff music educator. The
To the best of our knowledge, this study is one of the first to educator had completed the master’s degree in psychology of
evaluate the effect of Orff-based music therapy in children with exceptional children. Since there was no official training for
ASD. Previously, 2 studies did evaluate the Orff approach and its music therapists in the University or in other educating facili-
effects on grieving processes and a second on hospitalized chil- ties in Iran, the woman providing the interventions was trained
dren. Both of these studies had significant outcomes in symptom using Orff music therapy guidelines and also using the
improvement of children with ASD.28,29 The purpose of this e-courses of American Music Therapy Association. She also
study is to determine the effectiveness of Orff music therapy followed the recommendations from American Orff-Schulwerk
on social interaction, verbal communication, and repetitive Association.
behavior of the children with autism. The intervention was done in 3 phases, which took about 5
months. Each phase contained 20 sessions. Each individual
participated in separate Orff music therapy sessions, 3 times
Methods and Participants a week, 20 minutes per session (Figure 1).
In this interventional case study, 5 children with a mean age of 3.8
years with autism who had no previous experience in music or play
therapy were recruited from the Behara autistic patients’ research
The Sessions and Phases of Intervention
clinic at Shahid Beheshti University, Tehran, Iran. All of the par- At the beginning, there was a concentration on developing
ticipants were examined independently by an experienced child communication between the therapist and the participants to
and adolescent psychiatrist and met the Diagnostic and Statistical enhance their communicative skills. The music instruments
164 Music and Medicine 5(3)

3 Sessions per Week

From week 1 to 7
First Phase Total: 20 Sessions
Session Duration: 20 minutes

3 Sessions per Week Total Duration:

Orff Music Therapy Second Phase From week 8 to 14 5 Months
Total: 20 Sessions
Session Duration: 20 minutes

Third Phase 3 Sessions per Week

From week 15 to 21
Total: 20 Sessions
Session Duration: 20 minutes

Figure 1. Orff music therapy interventions: phases’ and sessions’ diagram.

that were used in this study were designed for the children by minutes and without any music. And then she or he
Sherlock Orff in 1928,4,32 which included a hand drum (25 repeated the intervention for another 3 minutes while
cm in diameter) and a xylophone, which were placed at 2 dif- the live piano music was played by the guide.
ferent sides of the office with a distance of 4 m between each 4. The child was asked to move a stick with a ribbon
other. These instruments can be played easily by children and (5.2  1 cm) right and left while she or he was listening
can be played simply by beating them with a handheld mallet. to a greeting song with music for 3 minutes and then to
They can also be easily transported and stored. On the other the same greeting song without music for another 3
hand, by listening to the accompaniment of these 2 instruments, minutes. The greeting song that was chosen was one the
the children experience both base and treble voices at the same most famous greeting songs in Iran, which was played
time. These instruments offer a sound texture of high quality in kindergartens and was also used by Iranian parents
and charm, with minimal instruction. to teach their children the greeting words.
The therapeutic sessions were designed based on the child’s
skills and interests that were observed by the therapist at the
preliminary session. The therapist initiated the therapy with
simple rhythms and then developed them into more compli- Second Phase. This phase included the following steps:
cated ones. In this study, there was a focus on using the Orff
music to develop communication between the therapist and the 1. The child was asked to go across the 2 music instru-
participant. ments including the hand drum and xylophone that were
used in the first phase, for 3 minutes while she or he was
First Phase of the Orff Music Therapy. At the beginning of this listening to a recorded famous Persian children’s song
phase, the therapist communicated with the children by focus- (‘‘My White Ball’’) without the music and also per-
ing on music, rhythm, and also their movement. This phase forming the task for another 3 minutes with the same
included the following steps: song with music. In this step, the child got assistance
from the guide.
1. The child came to the office without the parents and lis- 2. While the child stood in front of the guide, she or he was
tened to the music that was played live by the therapist asked to hold the therapist’s hands and to shake them to
using a piano for 5 minutes. This music was inspired by the right and left for 3 minutes while playing the recorded
a very popular children’s TV program music in Iran. famous Persian children’s song (‘‘My White Ball’’) with
2. With the help of the guide, the child was asked to play the music, and for another 3 minutes while playing the song
xylophone and the hand drum (25-cm diameter) that were without music.
placed at 2 different sides of the office with a distance of 4 3. The child was asked to move a 50-cm long stick with two
m from each other. She or he was asked to walk between 5.2  1-cm ribbons on to the right and left following the
the instruments and beat each of them once with the mallet therapist, for 3 minutes with listening to the same greeting
that the therapist gave him or her. The child was asked to song that she or he heard in the last phase with music and
repeat this task for 3 minutes without any music, and then for another 3 minutes without music. In this phase, the
repeat it while the therapist was playing the live music child was asked to repeat the greeting words that she or
piece that she played at the first step. he heard in the played song. The purpose of this task was
3. In this step, the child was asked to play the hand drum to focus on improving both the communication and lan-
with the mallet, first with the help of the guide for 3 guage skills of the child.
Dezfoolian et al 165

Table 1. Preinterventional and Postinterventional (Orff Music Therapy) ADI-R Scores of the Participants.

Before Orff Music Therapy After Orff Music Therapy

Participant Social Interaction Verbal Communication Repetitive Behavior Social Interaction Verbal Communication Repetitive Behavior

1 20 16 10 13 12 7
2 20 14 10 12 10 5
3 21 12 7 13 9 6
4 22 12 10 18 8 8
5 20 22 11 14 13 9
Abbreviation: ADI-R, Autism Diagnostic Interview–Revised.

Third Phase. The third phase included the following steps: short crying spells, and then he repeated this behavior. In the
first phase, he did not obey at all and he was throwing things,
1. The child played the music instruments that were used such as the playing mallet, away. In the second phase, he was
in the previous sessions for 3 minutes with, and for more attentive to the therapist’s lead. In this phase, he engaged
another 3 minutes without, the live piano music that the with the therapist and seemed more interested in music. He was
guide was playing. more receptive and no longer presented with urinary inconti-
2. While the child stood in front of the therapist, she or he nency. In the third phase of the study, his speech and verbal
was asked to follow the movement of the guide’s hands communication were significantly improved and he was able
and shake the guide’s hands for 3 minutes while ‘‘My to repeat the greeting song words. He also started communicat-
White Ball’’ was played and for another 3 minutes ing with the therapist by holding her hand and following her
while the same song was playing with music. In this ses- moves as he was asked to. His ADI-R scores for all the evalu-
sion, the child was asked to repeat the greeting words ated variables were reduced significantly after the Orff music
after she or he listened to the same greeting song in the therapy, showing improvement in his verbal and social commu-
previous phase. nications and also less repetitive behaviors (Table 1).
3. The child was asked to play the drum for 3 minutes Mani is a 5-year-old overweight boy without any biological dis-
without the music and then for another 3 minutes with orders, but was agitated at the first session attended. Based on his
the music while the child was singing a famous Persian parents’ observations, his heavy weight was a barrier to him as he
children’ song about pear. Since pear is one of the most was not able to play easily and had reportedly poor communication
favored fruits among Iranians, it was a tangible object with other children. He was constantly holding a loose string in his
for the children to relate with. Also, this song is being hands and was playing with it repetitively all the time. He would
repetitively played in kindergartens in Iran. repeat television advertisements and would make bizarre noises
4. The child was asked to focus on playing the xylophone such as a high-pitched brrrr or a knock-knock noise repetitively.
with the assistance of the guide. The purpose of this However, he was interested in music from the beginning and
step was to observe the child and evaluate how she responded to the rhythm by focusing on and listening to the music
or he communicates with the guide and plays the when it was played by the guide. However, he reacted to the loud
instrument. sounds by sealing his ears and running around the room. In the first
phase of the study, he made rhythmic movements fluidly, but in the
second phase, he was not able to sing the song’s words and his ver-
The Participants bal communication was poor. In the third phase, he made eye con-
The characteristics of the participants before and after the Orff tact with the guide and he played the music instruments easily. His
therapeutic music are mentioned in the following. Also, the pre- verbal communication appeared to be improving. He could repeat
and postinterventional (Orff music therapy) ADI-R scores for the word hello after he was greeted by the guide, but he was still not
social interaction, verbal communication, and restrictive and able to use other words of the played greeting song. His ADI-R
repetitive behavior of each participant are shown in Table 1. scores for all the evaluated variables were reduced significantly
Aria is a 3-year-2-month-old boy without any physiological after the Orff therapeutic music (Table 1).
problem and no family history of psychological diseases such Nima is a 3-year-1-month-old boy who appeared agitated in
as autism or schizophrenia, but he had the following behavioral the first session of the study, did not respond to the guide, and
characteristics. At the first session, he had urinary inconti- repetitively said, ‘‘I want to be with my mother,’’ even in the
nency. He had poor eye contact with severe repetitive behavior presence of his parents. He did not appear to have control of his
such as rubbing his ears with his hands most of the time. When hands, and he was not able to play the musical instruments. In
stopped, he would hit his head on the floor. He was interested in the first and second phases of Orff therapeutic music sessions,
climbing onto the chairs and tables and jumping off them. At he began to achieve control of his hands. He could hold the
the first session of Orff therapeutic music, the child went to the mallet himself and play with the instruments. In the third
corner of the room and rubbed his ears; stopping him resulted in phase, his social interaction with the guide and his verbal
166 Music and Medicine 5(3)

Table 2. Pre- and Posttherapy Mean Scores of Social Interaction and t-Test Analysis.

Social Interaction Mean Scores N Standard Deviation Standard Error Mean df t Significance

Pretest 20.6000 5 0.89443 0.40000 4 8.820 .001

Posttest 14.0000 5 2.34521 1.04881

Table 3. Pre- and Posttherapy Mean Scores of Verbal Communication and t-Test Analysis.

Verbal Communication Mean Scores N Standard Deviation Standard Error Mean df t Significance

Pretest 15.2000 5 4.14729 1.85472 4 7.7644 .011

Posttest 10.4000 5 2.07364 0.92736

Table 4. Pre- and Posttherapy Mean Scores of Repetitive Behavior and t-Test Analysis.

Repetitive Behavior Mean N Standard Deviation Standard Error Mean df t Significance

Pretest 9.6000 5 1.51658 0.67823 4 3.833 .019

Posttest 7.0000 5 1.58114 0.70711

communication were improved. He repeated the greeting His ADI-R scores for all the evaluated variables were reduced
words. His ADI-R scores for all the evaluated variables were significantly after the Orff therapeutic music (Table 1).
reduced significantly after the therapeutic Orff music sessions The mean ADI-R scores of all the evaluated variables were
(Table 1). reduced significantly. The results are shown in Tables 2, 3, and
Omid is a 3-year-old boy with severe repetitive behavior 4. The reduction in the ADI-R score was determining a good
involving his hands. Omid has the habit of constantly rubbing improvement in the course of the disease.
his hands together after exploring and touching everything in
the room such as the music instruments, the camera for
recording the sessions, and even the doorknob. He was run- Discussion
ning all over the room and appeared to have severe problems There are a variety of creative methods that may be available,
communicating with the outside world. He was also very which might improve the verbal and communicative skills of chil-
aggressive. He was knocking on the door from inside and was dren with ASD. The purpose of this case study was to determine
hitting the therapist when she was trying to get close to him. In the effectiveness of Orff therapeutic music on social interaction,
the first phase of the study, his symptoms were severe, and verbal communication, and repetitive behavior of children with
there was concern that even the therapy would be too threa- ASD. The results of the study revealed that all participants
tening for him. He was not able to play the music instruments, improved significantly in their social interaction and in their ver-
and he was throwing away the objects such as the mallet repe- bal communication based on the ADI-R. The Orff therapeutic
titively. He was resisting communication with the therapist. music program also seemed to help them decrease their repetitive
At the end of second phase, his repetitive acts were diminish- behaviors significantly. Results of the present study are consistent
ing, and he seemed interested in playing the music instru- with an overview of Orff music therapy that Melanie Voigt pub-
ments. In the third phase of the therapy, he started to lished in 2003.33 She revealed that the Orff music increases the
communicate with the therapist verbally with simple and sin- communication between the patients and the therapist and in addi-
gle words, and he showed increasing eye contact. His ADI-R tion helps the children with autism to improve their verbal com-
scores for all the evaluated variables were reduced signifi- munication and social interaction skills.33
cantly after the Orff therapeutic music (Table 1). A number of reviews investigating the use of music in indi-
Saman is a 4-year-9-month-old boy who appeared agitated viduals with autism have previously been conducted.15,34,35 In
and sensitive at the first session of the study and was crying most a Cochrane report by Gold et al, 3 studies were selected, which
of the time, as he was distracted and seemingly scared. After compared the use of music with nonmusic conditions in chil-
passing 8 sessions in the first phase, he was able to go to the dren less than 10 years of age, and significant results for ges-
music room without his parents, and he became more able to tural and verbal communicative skills during a music
concentrate on the music. In the second phase, he seemed to condition were reported, which are consistent with the results
be enjoying the sessions and was interested in playing music. of this study that compared music and no music conditions in
In the third phase of the study, he was able to play with the children with autism.35Although other methods of music ther-
instruments by himself. He played the xylophone in an explora- apy reportedly also had effects on child communication skills,
tive way and did not appear to need assistance from the therapist. the results of the present study illustrated the significant effects
Dezfoolian et al 167

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Declaration of Conflicting Interests with autism: a meta-analysis. J Music Ther. 2004;41(2):90-106.
The author(s) declared no potential conflicts of interest with respect to 16. Lim HA. Effect of developmental speech and language training
the research, authorship, and/or publication of this article. through music on speech production in children with autism spec-
trum disorders. J Music Ther. 2010;47(1):2-26.
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Author Biographies
physiological and psychosocial behaviors of hospitalized chil-
dren: a feasibility study. J PediatrNurs. 2013;28(3):249-257. Ladan Dezfoolian, MSc, Psychology of Exceptional Children, is with
30. Filipek PA, Accardo PJ, Baranek GT, et al. The screening and the Islamic Azad University, Central Tehran branch, Tehran, Iran.
diagnosis of autistic spectrum disorders. J Autism Dev Disord.
1999;29(6):439-484. Mina Zarei, MD, is with the Dermatology & Cutaneous Surgery
31. Lord C, Rutter M, Le Couteur A. Autism diagnostic interview– Department, University of Miami Miller School of Medicine, Miami,
revised: a revised version of a diagnostic interview for caregivers Florida.
of individuals with possible pervasive developmental disorders.
J Autism Dev Disord. 1994;24(5):659-685. Hassan Ashayeri, MD, is with the Tehran University of Medical
32. Lord C, Paul R. Language and communication in autism. In: Sciences, Tehran, Iran.
Cohen D, Volkmar F, eds. Handbook of Autism and Pervasive
Developmental Disorders. 2nd ed. New York, NY: John Wiley Majid Yousefi Looyeh, PhD, is with the Psychology Department,
& Sons; 1977:195-225. Islamic Azad University, Central Tehran branch, Tehran, Iran.

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