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Articles and Research on Rhythmic Entrainment Intervention (REI)
Calming Anxiety-Based Behaviors in Autism with Rhythmic Entrainment Intervention (REI) Drumming Rhythms
By Jeff Strong
Director, Strong Institute
Anxiety and Anxiety-based behaviors, such as self-stimulation, tantrums, aggression, and social withdrawal, are common issues among people with autism.
Rhythmic Entrainment Intervention (REI) is music-medicine program (Spintge and Droh 1992) that uses specific musical rhythms to stimulate and synchronize the listener's brain. REI employs custom-made recordings that are developed for each client. The musical rhythms selected for a client's recording are based upon an extensive intake process that uses 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 the theory that A. auditory rhythm can have a synchronizing effect on the listener's brainwave patterns (Maxfield, 1994) and B. 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 twenty years has suggested that listening to custom selected REI auditory tracks daily for 12 weeks results in improvements with many of the symptoms associated with autism (Strong 1998, Strong 2008, Strong 2014). Previous studies have shown that Rhythmic Entrainment Intervention (REI) provides positive gains for children with autism (Strong, 1993, Strong 1996, Strong 1998, Strong 2008, Strong 2014). The purpose of this study is to determine if REI rhythms can have calming effects for children in a school setting.
This study was conducted with ten children between 7 and 12 years old over a eight-week period at a public school. Each subject listened to a single custom-made REI recording once a day in the school setting according to a schedule that we determined best for them. Most of the children had their recording played at times when their anxiety and anxiety-based behaviors were at their worst.
Since 1994, thousands of people have used an REI recording and no observances of long-term negative reactions have been demonstrated. Any transient negative responses to the recordings have been alleviated by withdrawing the recording for two or three days or by turning the volume down to a barely audible level.
Methods and Results
I began this study by meeting with each child privately and observing how they responded to a variety of REI drumming rhythms that were documented to calm anxiety in children with autism. Each subject's custom-made REI recording was created based the REI Custom Program Intake and on their responses to my live performance.
Teachers or teacher aids were instructed to play each subject's recording at least once a day at a time when the subject was displaying anxiety or anxiety-based behaviors such as emotional outbursts self-stimulatory behaviors, or aggression. Some children experienced generalized anxiety and, in these cases, the subjects listened at a time when this anxiety was generally at its worst during the day or when it was convenient for the teacher or aid to play it.
The 10 subjects in this study were each unique in their presentation of autism and each displayed their anxiety differently. Following is a brief categorization of each subject in this study. A more thorough description of each child, their challenges, and responses to the REI drumming, both live and recorded, follow:
- Steve: Age 10; Male; Aggressive, non-verbal, hypersensitive to sounds.
- Jenn: Age 9; Female; Seizures, non-verbal, unresponsive, withdrawn.
- Nancy: Age 12; Female; Aggressive and non-compliant, extroverted, highly verbal.
- Kyle: Age 7; Male; Non-verbal, aggressive, hyperactive, hypersensitive to sounds.
- Tomas: Age 10; Male; Verbal (non-communicative), hypersensitive to sounds.
- Sandra: Age 9; Female; Withdrawn and Non-verbal.
- Mark: Age 11; Male; Highly verbal (non-communicative), compulsive, non-compliant.
- Carlos: Age 8; Male; Withdrawn and quiet, limited verbal.
- Keanan: Age 9; Male; Non-verbal, withdrawn, emotionally reactive.
- Lila: Age 11; Female; Non-verbal, unresponsive, withdrawn, self-stimulatory behaviors.
Steve was a non-verbal and physically aggressive 10 year old who was extremely sound-sensitive. I was warned when his teacher brought him to the evaluation room that Steve was especially reactive to high-pitched sounds. She insisted on remaining in the room because she was convinced that he would act out aggressively when I played.
I began slowly and quietly, playing with just the tips of my fingers. He sat and watched me with his teacher at his side. I played calming rhythms with this light touch for about six minutes when another child began screaming outside. Steve shifted in his seat and looked toward the door. His teacher started to stand up when the psychologist motioned for her to remain seated. We all watched Steve as he visibly tensed. Ordinarily this type of incident would send Steve into hysteria. He would become very anxious and throw himself around, often screaming. In this instance Steve just sat there. He was clearly aware of the other child's screams and he got tense; but as I played soothing rhythms based on a Cuban Son rhythm, he managed to stay in his seat and keep to himself.
The screaming child stopped screaming after just a few minutes and Steve settled and everyone else in the room seemed to relax. 5 minutes or so after the child stopped screaming, I switched to more energizing rhythms because Steve seemed so calm that I wanted to see if he was paying attention to my drumming. Two minutes into these invigorating rhythms and Steve came over to the drum and tapped on it with me. We played together for a few minutes and I stopped. He kept on playing for about 30 seconds and then simply held onto the edge of the drum. I thanked him for letting me play as the teacher escorted him out of the room.
Steve generally listened to his recording right after lunch, which was a tough time for him. The transition from the largely unstructured mealtime to the more structured work time often elicited a tantrum or aggressive outburst. According to tracking documents and teacher reports, Steve was calmed by his REI recording 89% of the time during these outbursts or aggressive attacks. Teacher reports also showed that his anxiety in general was down from the start of the study.
Jenn was a non-verbal, low arousal and withdrawn 9 year-old. She had a seizure disorders that required her to wear a helmet in the event that she had a seizure and fell, which happened often (several times per week at school). Jenn was very passive and sat quietly during the entire 20 minutes that I played for her initial session. She sat up and became more alert when I played bass-heavy triplet-based rhythms. Many other rhythms that spurred a calmed response in other children had no noticeable impact with her. It may have been the result of the seizure medications she was taking.
Jenn never really got anxious, so evaluating the calming effects was somewhat difficult. Her teachers did notice, however, that she seemed to focus better as the recording played, so they made a habit of playing it while they were working on tasks that she was often distracted from. Her teacher noted that Jenn "will sit by the player while listening to the REI recording. She has shown some increase in group participation and staying within the group setting".
Nancy was a highly verbal, though often inappropriate, extroverted, non-compliant and somewhat physically aggressive 12 year-old. Nancy was quite a force. She entered the room singing a Disney movie song. She engaged with me to the extent that she sang and danced around me, so I just jumped in playing. I started with basic calming rhythms, which had ??no impact initially as she kept on singing and tried dancing with the psychologist. After about 3 minutes she abruptly stopped singing, turned to me with a serious look and put her hands on the edge of my drum. I stopped playing.
Nancy then began telling me how great I was and how awesome my drumming was. I tried to thank her and start playing again but she kept on, telling me just how amazing I truly was. This exaggerated praise lasted for several minutes until I decided to start playing again. Once I did, she began singing and dancing again until she tripped and fell into the recorder. I kept playing, lowering my volume and rhythmic intensity, as the psychologist held her. She didn't get hurt when she tripped and did not seemed bothered by the incident. She did, however, sit next to the psychologist when he directed her to the chair next to his.
I played for another 12 minutes and stayed with low intensity, relatively simple rhythms to see if she would calm. She did. By the end she was quietly sitting and drawing with a pencil and paper that the psychologist gave her. He led her out of the room and she followed him quietly.
Nancy listened to her REI recording several times a day. Her teacher and caregivers tried to time her recording to when she was aggressive or agitated. I didn't witness this the day I played for her, but Nancy had several aggressive incidents each day in school. These usually involved pushing and grabbing fellow students or school staff. These incidents didn't come out of nowhere - there was generally some initial agitation that could be seen before Nancy acted out. The staff chose this time to put on her REI recording in the hopes that it would stop or at least reduce her aggressive behavior.
The teacher reported to me that Nancy responded well to her recording, calming every time she heard her recording. She also said that whenever Nancy listened while in one on one care, she fell asleep to the recording. It wasn't uncommon for Nancy to listen to her recording more than once a day.
Kyle was a highly aggressive, hyperactive, non-verbal 7 year-old. He was also sensitive to sounds and acted out aggressively, hitting and scratching others if he encountered a loud or irritating sound. His teacher warned me of this when she brought Kyle to my room. She said he would likely jump around and grab things and that I should be careful not let him get behind me because he was known to grab hair and scratch.
Kyle did, in fact, bounce around the room when I began playing but he settled down within abut three minutes. I was careful to play quietly without abrupt changes in rhythms or timbral characteristics. Like with the other sound sensitive students, I avoided slap tones.
At about five minutes, Kyle sat down in a chair and chewed on a plastic toy. He giggled a few times as I played - mostly during the short, triplet-based, odd-rhythm patterns (rhythms in 15/16 or 17/16 time signatures). I played for for almost 20 minutes and at times got pretty loud, but Kyle never seemed to be bothered by my drumming.
Overall, Kyle was calmed by his daily REI recording. Many times he began the recording when he was in a very agitated state and the recording calmed him for each of these episodes. Teachers noted that he was overall less aggressive than at the beginning of the study.
Tomas was a highly vocal, though non-communicative, 10 year-old who was described as being extremely sensitive to sound. When the teacher brought Tomas to the room for me to play, she warned me that he may respond negatively to the drumming. She asked the psychologist to keep a close eye on him as he tended to lash out aggressively when sounds were too much or too loud for him.
I began playing very quietly, being sure to not play any rhythms that had "slap" tones (high-pitched, overtone rich sounds produced by squeezing with the fingers while hitting the edge of the drum). Tomas stood in front of me as I played, often pushing my hands off the drum. He also vocalized the entire time and occasionally hit the drum. I found that slowing the rhythms down a bit (to about 6.5 beats per second) and avoiding the slap tones worked best. In spite of his high degree of sound sensitivity, he never got aggressive, agitated nor covered his ears while I played.
It was reported that Tomas was consistently calmed by his REI recording for the first two weeks, but became somewhat agitated by it during the third week. As it happens his recording was destroyed by another student after the third week. As this same Tomas began requesting to listen to another student's REI recording. This one was calming for him for the rest of the study period. According to post-study evaluations, Tomas showed some overall improvement in his response to sounds that used to bother him. He also exhibited less anxiety and agitation in general.
Sandra was a low arousal, non-verbal, 9 year-old who was socially inhibited. Sandra was led to the evaluation room by the school psychologist. She made no eye contact as I said hello. During the entire time I played for her (approximately 20 minutes) she sat quietly next to the psychologist. She seemed to like the drumming - there were a few occasions where she smiled as I played triplet-based rhythms. Like several other children in this study, she responded favorably to variations in a Brazilian Naningo rhythm. These variations took the traditional 24-beat pattern and extended it to 43 beat rhythm.
When I met with the staff at the four week point, her teacher reported that she "loves" her REI recording and often carried it around with her. She listened at least once each day and, though she wasn't always agitated or exhibiting anxiety when it was turned on, she seemed to "settle" a little as it played.
At the end of the study, her teacher asked for a copy to send home with Sandra because her mother requested it. According to the teacher notes, "Sandra loves listening to her recording. We have seen increased eye contact, less refusals, and shorter latency to respond to requests".
Mark was a very vocal, hyperactive, compulsive and non-compliant 11 year-old. When Mark entered the room he came right up to me and started hitting the drum while talking and asking me questions. "Why are you here?", "Are you going to play the drum?", "Could I play with you?", "What kind of drum is it?", "What's that there?" and on and on. The psychologist attempted to redirect him after a couple of minutes, but Mark squirmed away and grabbed at my microphone. The psychologist caught his hand but Mark leaned in and started singing into it.
I began playing very quietly. Mark stood up, placed his hands on the drum and continued asking me questions and talking non-sensically. After a few minutes he moved from the drum and walked around the room while he continued talking. At about the 10-minute point, the psychologist asked him to sit down. Mark complied. He remained sitting for the next ten minutes as I played.
Based on his activity level as I played, he seemed to calm to very straight, structured rhythms. The most calming for him were variations on a Brazilian Samba rhythm. Slight variation is important to keep it from becoming repetitive, so I started with basic 4-beat Samba (loud-soft-soft-loud pattern) and kept growing this pattern two-beats at a time until the rhythm evolved to a 31 beat pattern. This 31-beat Samba was what I was playing when the psychologist was able to get Mark to sit down.
Two weeks into the study, Mark's home life was upturned when his father moved out. According to his teacher, Mark was consistently arriving at school agitated. His teacher started playing Mark's REI recording first thing in the morning. It calmed him, but as the day wore on he would become agitated. Many days they also played his recording in the afternoon and it calmed him.
At the four-week point, both the tracking forms and Mark's teacher described that he was consistently calmed by the REI recording.
At the end of the study his teacher reported that he was still calmed every time the REI recording played. She also noted that "Mark has been able to better express a variety of feelings as well as use quiet times to calm himself during anxiety. We also have seen increased group participation".
Carlos was a quiet, withdrawn 8 year-old male with limited verbal skills. At our fist meeting, Carlos sat with a playing card in his hands, which he flexed rhythmically as I drummed. He occasionally looked at me and the faintest of smiles appeared whenever I played triplet-based rhythms. During one particular unusual rhythm, a variation on a traditional Brazilian Naningo rhythm, he moved his legs to the rhythm while flexing the card.
I also noticed as I varied the tempo and pulses that he seemed to be trying to flex the card in time with me. At one point, to test this theory, I slowed my rhythm and pounded out a steady pulse to see if he would join me. He did.
Interestingly, he also seemed to have a keen sense of my rhythms, which were complex by most musical standards, and flexed his card in syncopations to meet mine. This is something I have seen more than once in children on the autism spectrum. Not the flexing of a card, but an apparent understanding of rhythmic complexity. Complexity of REI rhythms is one aspect that allows listeners to engage in the music and what seems to give the stimulus its effect, and along with progressive levels of stimulation, to allow for a lasting change.
I played for Carlos for a total of about twenty minutes. When I stopped he smiled again. I asked if he liked the drumming and he said yes.
According to his teacher and the tracking notes, the recording was consistently calming for Carlos. He often listened to his REI recording with headphones while doing schoolwork. In one instance his teacher noted that while the recording played he finished his work and when the drumming stopped, he took the homework and the recording to her.
Keanan was a non-verbal, socially-withdrawn 9 year old who was highly reactive to other children who impeded on his space. I was playing quietly when Keanan entered the room. He immediately came over to me and put his hands on the side of the drum. I kept playing, adding some bass tones and ramping up the volume to a typical level for the children in this size room. Keanan giggled as the I hit the bass tones. After about 4 minutes of holding onto the drum and giggling as he felt the vibrations of the deeper tones, Keanan crawled under the drum. He positioned himself at my feet with his abdomen directly under the hole of the drum where the bass tones are most prominent and he stayed there as I played for another ten minutes. I was careful to keep the volume fairly low so that it would not damage his ears, but I also played rhythms with an abundance of bass tones so he could feel the drum as much as possible. He clearly enjoyed this as he giggled and smiled during the more bass-tone heavy passages.
Keanan, according to the tracking notes, was calmed 100% of the time that he listened to his recording. His teacher noted that they chose to play it when he seemed to be getting bothered by the proximity and activity of nearby students. Because his recording was played within the larger classroom (he never had one-on-one aid outside the classroom), his teacher used his recording to not only calm him but to help create what she described as a "calmer classroom environment". She reported that this not only helped calm Keenan and keep him from acting out toward others, but also that all the students present seemed to be less on edge while the recording played.
Lila was a very withdrawn, non-verbal 11 year-old who had extreme self-stimulatory behavior. I was only able to observe, and not play for, Lila the first time I met her. I noticed that although she was very quiet she seemed very anxious, constantly tugging at her hair in an agitated manner. This behavior was apparently nothing new because she had several bald patches on her head. Lila's teacher described that she spent a lot of time engaged in this self-stimulatory behavior.
I created Lila's REI recording based on the data I collected from playing for the other children. When I dropped off her recording I had the opportunity to play for her and to confirm the I had chosen the right rhythms for her. Lila sat quietly as I played. She didn't react strongly one way or the other, but she did stop pulling on her hair after 6 minutes of my drumming. I noticed, like many of the other children in this study, that she seemed to calm to a series of rhythms based on traditional patterns from Cuba and Brazil. These rhythms were all in odd time signatures with individual beats added on or cut off, giving them an unpredictable feel.
According to teacher reports and her tracking documents, Lila was calmed 100% of the time by her recording. This calming was also almost immediate, usually resulting in her stopping her stimming behavior within the first minute of the recording.
All of the ten children in this study were calmed by their Rhythmic Entrainment Intervention (REI) recordings, many every time they heard their custom recording. Anxiety reduction can take many forms, especially with the large variation of symptomatic behaviors and characteristics present in children on the autism spectrum. This study illustrates this with anxiety manifesting in the following ways:
- Emotional outbursts. Tantrums and other emotional outbursts are common responses to external stimuli with children on the autism spectrum as they often present negative response to sensory input, changes in their environment, and difficultly expressing themselves verbally. The REI drumming proved to help with these emotional outbursts. The recordings were especially effective for Steve and Kyle, who were often highly anxious at transition periods and who were emotionally reactive in general.
- Self-stimulatory behaviors. Hair pulling, chewing, picking, eye movements, and others, are often thought of as ways of modulating or tempering sensory input and, as such, may be a anxiety-like response to environmental factors. Two subjects in this study, Carlos and Lila, exhibited self-stimulatory behaviors and both showed a reduction in these behaviors during the course of the study. Lila was especially calmed by her recording, resulting in a consistent cessation of her self-stimulatory hair pulling when the recording was played.
- Aggressive behavior. Aggressive and violent behavior is often the most challenging behavior that teachers and their aids have to confront each day with children on the autism spectrum. This study contained several children who acted out aggressively when over-stimulated, including Steve, Nancy, Kyle, and Keanan. The REI recordings nearly always resulted in a reduction of aggressive behavior in these subjects. This not only helped the aggressive child calm down but also aided in reducing the overall anxiety in the room in which these children acted out. In the case of Keanan, for example, playing the REI recording when the first signs of agitation appeared kept him calm and seemed to relax the entire room.
- Generalized anxiety. Generalized anxiety is common with children and adults with autism. For some it manifests as a reactivity born our of hyper-vigilanace, as demonstrated by Keanan, and for others it is an internal tension leaking out as a self-stimulatory behavior, as seen with Lila who constantly tugged on her hair. In this study we relied on the more obvious manifestations of this anxiety as a baseline for seeing the effects of the REI recordings. However, many teachers reported that they noticed a much calmer environment and more easily directed children as a result of having the REI recordings at their disposal.
- Sound Sensitivity. Though not seen as an anxiety-based behavior but rather as a trigger for anxiety for many, sensitivity to sound is another common trait in people on the autism spectrum. Several children in this study, Steve, Skyler, Tom, Kyle, and Tomas exhibited this characteristic. This study didn't track sound sensitivity level for these subjects, but it did document how the REI recordings contributed to the reduction of anxiety when it was triggered by loud or unexpected sounds.
Given the results of this study, the next step would be to repeat this study with larger populations and with other ages groups, such as very young children, teens, and adults. Other follow up studies should attempt to focus in on specific behaviors and to look at longer term results.
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