Rhythmic Entrainment Intervention For Adults With Autism: A Pilot Study

Note: This is an exerpt from a study to be published in the Journal Zoe, from St. Dunstan's Press, Mt Angel. The full text will be available when the study is published.

by Jeff Strong

This paper is developed into two major parts. In the first section, I will introduce readers to the theoretical frameworks of Rhythmic Entrainment Intervention (REI); describe the methodology of this pilot study; and a provide a brief synopsis of some of the general themes and issues relevant to adult autism. 

In the second section, I will present brief thumb-nail descriptions of four residents at a group home facility specializing in the needs of the autistic adult.  These brief descriptors are called Patient Profiles, and highlight language employed by the facility and staff.

The remainder of the second section presents four fairly detailed case studies.  Each case study sets the stage for the reader by providing excerpts from the medical and psycho-social history and records as documented at the facility.  Again, these notes tend to be verbatim excerpts.  These prefatory remarks are then followed by my own REI Clinical Narrative.  Each clinical narrative is followed by general progress notes or outcomes assessment notes charted by the staff at the facility.  These notes document phenomena observed over a 6-month period where the REI program was employed. 

I conclude the study with a few general remarks about outcomes, ask a few questions, and describe future directions for our continued research. 

Theoretical Frameworks:

Rhythmic Entrainment Intervention (REI) is a music-medicine program (Spintge and Droh 1992) that employs musical rhythm to stimulate and synchronize the listener’s brain. REI employs custom-made recordings developed for each client based upon an extensive intake process using variations on the standardized rating scales used to diagnose neurobiological conditions (the Aberrant Behavior Checklist and Connors’s Rating Scale, among others). REI is based on two theories.  First, auditory rhythm can have a synchronizing effect on the listener’s brainwave patterns (Maxfield, 1994).  Second, complex rhythms can have an activating effect on brain activity even in people with severe neurological disorders who otherwise have low brain activity levels (Ostrander and Schroeder 1994, Parsons 1996, Rossi 1986, Scartelli 1987, Scartelli 1992, Shatin, et al 1961).

Research on REI over the last fifteen years has suggested that listening to custom selected REI auditory rhythms daily for 16 weeks results in improvements with many of the symptoms associated with autism (Strong 1998, Strong 2008). Previous studies have shown that Rhythmic Entrainment Intervention (REI) provided positive gains for children with autism (Strong 1996, Strong 1998, Strong 2008). The purpose of this newer study is to determine if REI rhythms can have similar effects for adults as have been seen in children.

Since 1994, thousands of people have used an REI recording and no observances of long-term negative reactions have been demonstrated. We have painstakingly documented any report of transient negative responses to the recordings, and have noted that these have been alleviated by withdrawing the recording for two or three days or by turning the volume down to a barely audible level.

Methodology of Pilot Study:

This study would be conducted over a six-month period at a private residential care facility that housed five adult males, ages 23-38.  Through a collaborative decision between the facility and REI, it was decided that four of the residents would be enrolled in the study.  The fifth had just begun taking medication for a seizure disorder (Tegritol).  Since the effects of this medication on the subject could not yet be known, it was decided that there would be no objective manner of differentiating between what might be an REI response from what might be a Tegritol response.  

Each subject would listen to a single custom-made REI recording once a day, every day,  at bedtime.  The facility would also play a generalized REI recording during the day in the common rooms when anyone showed signs of anxiety or agitation.

The design and realization of these custom-made REI recordings[1] would be created only after a two-pronged assessment process had been completed.  First, REI would conduct a clinical observation period of the subject. Second, a careful intake interview would be jointly conducted by REI, staff and the facility director. 

The General World of Adult Autism:

This is not an exhaustive list or description of issues, but rather a thumbnail inventory of some of the most demanding themes that are evidenced in adult autism and as a result, become issues for both patients and providers. 

  • Aggression. Aggression can surface in a wide variety of behaviors, physical, emotional and psychological, having a very difficult negative impact for the patient, the other residents in a group home, and for the staff of health care providers.  Typical phenomena: spitting, yelling, screaming, explosive irritation, gestures and motions that threaten others, are unaware of or disregard boundaries of personal space for others; taking or stealing other resident’s food or belongings; grabbing, stomping, pushing, shoving, hitting, etc. 
  • Self-Stimulatory Behaviors.  Stereotypic self-stimulatory behaviors can be visual, auditory, tactile, vestibular, or directed towards taste and smell.  Simple quiet rocking is an example of a self-stimulatory behavior that can be calming in small doses.  General phenomena can include all kinds of patterned activity such as staring at lights, repetitive blinking, moving fingers in front of eyes, tapping ears, snapping fingers, rocking back and forth.  Self-stimulatory behaviors become a clinical concern when they become self-abusive or self-injurious.  Examples can include repetitive scratching, finger-nail biting, hitting head against the wall, anal digging, etc. 
  • Anxiety. Manifests in wide variety of expressions at multiple levels:  physiological, psychological and psycho-social. These can include everything from trouble processing fear, to high blood pressure, to over-eating, to exhaustion, pacing, twitching, nausea, problems with continence, weight loss or gain, etc.  
  • Sleep Disorders:  Disturbed sleep patterns, sleep cycles and sleep quality can be demonstrated in either direction of sleep deprivation to excessive sleeping.  
  • Bipolar cycle. Whether in manic or depressed cycle, the shifts can be so extreme as to leave the subject incapacitated.  This autism study was particularly exploring the possibility of the capacity of REI to shift either depth or duration of cycles and their swings.

Simple Patient Profiles

The subjects in this study were each experiencing different issues and different clusters of issues.    

Because the REI Custom Program is individually recorded for each person, the clinical goals for the delivery of rhythm are uniquely and individually tailored for that single recipient.   

The following is an initial condensed identification of the issues which the facility chose as the focus of the REI clinical care.   The descriptive terms employed in the Patient Profiles related to diagnosis, prognosis, and current phenomenology are those originally used by the facility staff, not by REI.  In this publication, we are choosing to carefully reproduce verbatim terms which the facility or facility staff members use or employ in their patient histories. 

  • Subject 1: Jim – Male, age 26. Autism, non-verbal. Focus facility wanted to address during this period concerned self-stimulatory behaviors; anxiety, aggression, sleep deprivation, listening ability and compliance issues.
  • Subject 2: Billy – Male, Age 27. Autism, non-verbal. Focus facility identified was on anxiety and self-injurious behaviors such as biting.  
  • Subject 3: Russell – Male, Age 38. Autism and bipolar disorder. Focus facility wanted to address during this period included self-stimulatory and self-abusive behaviors, anxiety, disturbed sleep cycles resulting in a full spectrum of alternate swings between excess and deficienc7, and bipolar cycles, particularly the depressed cycle.
  • Subject 4: Carl – Male, age 35. Autism. Focus facility wanted to address during this period included aggression, self-stimulatory behaviors, anxiety, and sleep issues.

[1] The REI Program recording used in this earlier study was the precursor to the current program that is currently dynamically created for each client. During this particular study, only one recording was created for each person, however it was custom made.  Our subsequent research has shown that an entire series of  (8 to 16 or more) uniquely created, one-of-a-kind CD tracks is substantially more effective.  When we can respond dynamically to the patient’s needs and responses, our patients show more consistent and significant overall improvement.  No single patient ever receives the same deliveries, tracks or sequences that any other has received. 

Body eliminated until the study is published.

General Results for the Group

On a global scale, after sixteen weeks of using the REI recordings for each of these individuals, the staff reported that there had been no violent or aggressive incidents documented within the facility for a period of three months.  To contextualize this, prior to the implementation of the REI program, there had been two to three documented outbreaks per week. 

The staff reported that the residents were generally more calm and cooperative. They also reported that all residents were getting to sleep within 30 minutes of turning on their recordings and all the subjects seemed to enjoy listening to their recordings and several would turn them on by themselves.

The results of the REI recordings for the four subjects were unique to each individual and were in concordance with the issues the REI recordings were designed to address. Similarities existed in several areas. These similarities included:

  • Aggression Decreased: The subjects who displayed aggressive tendencies stopped doing so while using the REI recordings. The facility had no incidents of aggressive incidents after the first week of the study.
  • Self-stimulatory behaviors. All subjects with this issue demonstrated significant improvement.  Incidents of self-stimulation decreased and incidents of self-abusive or self-injurious behaviors decreased.
  • Anxiety. All subjects demonstrated observable, significant psycho-social and biomedical improvement either while the recordings played our long-term beyond when the REI recording was playing.
  • Sleep. All subjects with sleep disturbances demonstrated significant improvement in their sleep patterns and cycles and in the quality of restorative sleep acquired; subjects fell asleep more quickly and were able to sleep longer and more deeply.
  • Bipolar cycle. The one subject with bipolar disorder experienced a reduction in the depth of the cycles and in the durations of the depressed cycle.

Conclusions:

While each subject entered the study with unique goals and each REI recording was custom-made for each person, many similarities existed among their responses in the areas of anxiety, aggressive behavior, self-stimulatory behaviors, and sleep.

These issues are common among most people with autism and previous studies with REI have suggested that these, among other areas, can be helped using a custom-made recording of Rhythmic Entrainment Intervention. There are two important factors that may be leading to these types of improvements with REI.

  • First, anxiety is a major concern for most people with autism. Anxiety is often a contributing factor in other areas such as self-stimulatory behaviors, aggressive behavior, and the ability to fall into and stay asleep. Reducing anxiety in a facility attending to the special needs of autism can be the single most clinically beneficial and cost effective outcome provided for both residents and staff. This pilot study demonstrates that the overall calm that developed in the environment was very life-enhancing for all, improved working conditions for staff, and results positive corporate factors such as reduction in emergency personnel hours, emergency medical incidents, etc.  
  • Second, poor sleep or disturbed sleep cycles negatively impact physiological emotional, mental, and psychological well being.  In those with autism, where communication is often already challenged or compromised, sleep deprivation exacerbates the situation.  It contributes to anxiety, one of the most vulnerable and labile conditions for this patient constituency. Good, restorative sleep reverses the situation, promoting emotional stability, well-being, reducing stress (anxiety). 

We learned a great deal from this study.  By 2011, the REI Custom Program applied changed protocols and began to deliver the dynamically created CDs described in the footnote at the beginning of the article.  Our patients now typically receive anywhere from 8 to 16 or more uniquely created deliveries of rhythm during the 16 week period of our phase-one clinical program.  We create new rhythmic deliveries as needed for each individual patient, and I am unaware of any other program making such uniquely attenuated deliveries of recorded rhythms for clinical uses, where documentation is fundamental to the outcomes-assessment process.    This ability to respond dynamically to the needs of each individual patient is precisely why our REI program has had such a positive and dramatic impact.   This dynamic responsivity results in more immediate, more predictable and more consistent improvement ratios or outcomes among different groups of people within our realm of experience, autism being one of these areas. 

Given the results of this particular study in combination with numerous case studies since implementing our 8 to 16 CD format, I remain very interested in developing new work for deliveries in other patient constituency areas. 

I am also very interested in exploring the use of brain imaging in conjunction with REI deliveries.  Not unrelated, it would be worthwhile to develop some sort of outcomes assessment or simple analysis directly related to finances. 

With this in mind, we at the Strong Institute look forward to publishing future studies that can explore four additional areas:   

  • What is the positive financial gain at a group home where improved psycho-social patient conditions directly lighten the work load for the staff and providers, from the director all the way to janitorial services?   
  • Is there a way to review the metrics for employee turn-over in a calmer work environment? 
  • How can we implement a research study that reflects increased or decreased uses of pharmaceuticals following a full and or ongoing REI program? 
  • Is there an application here for REI with emergency medical interventions?   

I would look forward to hearing from readers who have questions or comments, and may be reached at Jeff@StrongInstitute.com