Fostering Theory of Mind in ASD

Chomchat Silarat
Published online: 19 Jul 2021

Individuals with ASD display incompetency in developing the Theory of Mind (ToM), a mechanism that allows humans to interpret others’ intentions and reciprocate actions, leading to difficulty in social communication and interaction. The Simulation Theory of ToM proposes that the brain constructs a simulation of others’ states of mind through neural activities in the mirror neuron system; this neural circuit plays an essential role in action observation and imitation. In ASD, the mirror neuron system is believed to be malfunctioning. Consequently, much effort has been put into finding cures for this deficiency, leading to developing interventions that involve motor imitation, such as music therapy. While the positive effect of music on imitation is profoundly recognised in a therapy setting, other music-based practices such as lessons have not yet been widely explored. This literature review investigates whether piano lessons can become a potential tool to foster action imitation and ToM in ASD by exploring existing evidence regarding piano pedagogy and imitation skills in these individuals.

Autism Spectrum Disorder (ASD) is a developmental disorder characterised by difficulties with social communication and the presence of repetitive patterns in behaviours, activities, and interests (American Psychiatric Association, 2013). ASD was first clinically introduced and recorded by an American-Austrian psychiatrist, Leo Kanner (1943), although the condition likely existed through the ages (Volkmar & Klin, 2005). For decades, researchers and practitioners have put effort into explaining the underlying reasons for characteristics associated with ASD; a variety of theories were proposed, and the topic is still actively discussed nowadays.

The impairment in the Theory of Mind (ToM) is a potential explanation for the symptoms of ASD. ToM refers to the ability to ascribe mental states such as intent, knowledge, feelings, and desire to oneself and others through expectation, comprehension, internalisation, and understanding (Baron-Cohen, Tooby, Cosmides, Tooby, & Cosmides, 1997). The term was coined in 1978 by psychologist David Premack who conducted an experiment on a Chimpanzee, examining its ability to infer states of mind (Premack & Woodruff, 1978). Following the establishment of the concept, scholars have held various arguments regarding the explanation of ToM development and the neural mechanism behind it.

The mechanism of ToM primarily involves imitation, both verbal and non-verbal (Dadgar et al., 2017; Ingersoll, 2008; Livingstone & Thompson, 2009); hence, ToM deficiency is associated with impairment in verbal and physical imitation. A variety of studies acknowledge this impairment (e.g. DeMeyer et al., 1972; Ornitz, Guthrie, & Farley, 1977; Zwaigenbaum et al., 2005), and multiple forms of interventions have been developed to facilitate verbal and non-verbal imitation development in ASD (e.g. Hourston & Atchley, 2017; Kaur & Bhat, 2019; Reinders, Branco, Wright, Fletcher, & Bryden, 2019). The function of the neural system facilitating imitation is associated with higher-level human cognitive functions (Carr, Iacoboni, Dubeau, Mazziotta, & Lenzi, 2003; Gallese, 2003) and ToM (Williams et al., 2006; Williams, Whiten, Suddendorf, & Perrett, 2001); thus, nurturing imitation skills in ASD can potentially aid ToM development.

Music-making is a realm where action imitation and motor functions can be enhanced (Overy & Molnar-Szakacs, 2009; Wan, Demaine, Zipse, Norton, & Schlaug, 2010). Heaton (2009), in a literature review, acknowledges that individuals with ASD who are not savants possess a variety of talents in music, such as heightened sensitivity to pitch and accurate sound memory. In music therapy, practitioners leverage the sensitivity to musical stimuli to facilitate imitation and social communication skills in ASD (e.g. Møller, Odell-Miller, & Wigram, 2002; Sharda et al., 2018). Therefore, music has been commonly utilised for therapeutic purposes, especially for individuals with ASD.

While the relationship between music-making and imitation is widely established, only a few studies explore the use of a particular instrument. Møller et al. (2002) suggest that the use of piano in interactive music therapy is usually associated with the development of awareness and concentration practice, while percussive instruments such as drums serve to foster synchronisation and imitation. Nevertheless, despite possessing the quality of a pitched instrument, the piano is also percussive (Silarat, 2020a); therefore, its functions can potentially become more versatile. More studies on this topic can open up opportunities for practitioners to utilise the piano to foster other cognitive skills beyond what is currently explored.

Besides the instrument choice, the context of musical interaction is also pertinent to the rationale of this literature review. Music therapy is associated with the medical model of disability (Olkin, 1999), a model characterised by the emphasis on the treatment of the symptoms. This school of thought endorses the idea of attributing the patient role to the learner, perpetuating the belief that persons with disabilities can only develop various skills in clinical settings (den Houting, 2019, November 1). Therefore, musical interactions in the form of music therapy for ASD serve the sole purpose of fostering cognitive development (such as social communication skills), thus limiting the learners’ opportunity to interact with the teacher in ways that neurotypical individuals typically do (Holczer, 2018). On the other hand, music lessons allow the learner to receive personalised instruction and achieve musical goals (Hopper, 2016, July 21). This form of musical interaction corresponds to the social model of disability (Oliver, 1981), which attributes the limitations in a particular group of individuals to the society and environment. Practitioners and researchers who subscribe to this model believe that disabled individuals are human beings who deserve equal opportunities in education (e.g. O’Connell, Finnerty, & Egan, 2008; see Retief & Letšosa, 2018). When approaching ASD with this model in mind, interventions that facilitate the personalisation of the environment and interactive methods can be appropriate.

It is essential to acknowledge that both models are not entirely right or wrong. Society should respect disabled individuals and offer equal opportunities to learn and grow. At the same time, the neurological conditions of the disability should not be neglected. To find the middle ground, other forms of musical interaction outside the practice of music therapy should be explored. In an unpublished thesis, Silarat (2020b) investigates how ASD traits affect the musical mastery of students with ASD in a piano lesson context. Interviews with piano teachers in the study revealed that traits such as hyper attention to small details and accurate memory are beneficial for musical development. The teachers also reported that students with ASD demonstrate accurate action imitation and heightened interest in copying physical hand movements. Therefore, interactive music-making in the form of piano lessons may serve to foster imitation in ASD while allowing the students to learn and achieve milestones in similar manners as neurotypical individuals.

The purpose of this literature review is to investigate whether piano lessons can become a potential realm to foster ToM development in ASD by exploring existing evidence regarding piano playing and imitation skills. Neuroscientific evidence and literature from music educators are discussed collectively to provide an understanding of ASD as a developmental disorder and to grasp the current concepts in piano pedagogy. Based on the infancy nature of the topic, it is worthwhile to note that the purpose of this paper is not to compare piano lessons directly to music therapy nor to conclude that the former can become a replacement for the latter.

ToM Deficiency in Autism Spectrum Disorder: Mindblindness

One of the leading explanations for the impairment of social communication and interaction in ASD is ToM deficiency or Mindblindness: the idea that ToM mechanism in individuals with ASD is flawed (Baron-Cohen et al., 1997; Ramachandran, 2011). Baron-Cohen suggested that children with ASD usually display characteristics of Mindblindness which include the difficulty in understanding, imitating, and reciprocating others’ actions. ASD is categorised as a spectrum disorder due to the varying degree of severity in symptoms (American Psychiatric Association, 2013); hence individuals diagnosed with ASD will exhibit a heterogeneous set of symptoms associated with Mindblindness that are to be understood by caregivers, healthcare providers, educators, and surrounding people.

Within a social context, individuals with ASD demonstrate an understanding of basic physical behaviours; gestures that signify basic needs (such as to go away or to be quiet) are well comprehended by children with ASD, whereas gestures that imply mental states (such as expression of embarrassment, disappointment, and consolation) cannot be well recognised (Attwood, Frith, & Hermelin, 1988). Further, Baron-Cohen, Leslie, and Frith (1986) suggest that children with ASD are not capable of understanding intentional stories that demand discernment of mental states.

Another characteristic of impaired ToM is the inability to understand abstract information. Baron-Cohen (1989) indicates that individuals with ASD do not exhibit an understanding of the distinction between mental and physical entities: they cannot discern between the thought of an object and the object itself. This inability to understand abstract thoughts leads to a lack of appropriate emotional expression, verbal communication, and empathy towards others.

ToM development is associated with many aspects of development, including language use (de Villiers, 2007) and personal epistemology (Frye & Wang, 2008). Malle (2002) posits that the ToM mechanism is responsible for, but not limited to, language development, high-level functioning, joint-attention, and intention interpretation. Considering the importance of ToM, social communication impairment in ASD can potentially be alleviated if ToM development is fostered.

ASD and The Broken Mirror Hypothesis

Researchers proposed a variety of hypotheses regarding the mechanism of ToM (see Henderson, 1996; Livingstone & Thompson, 2009). Among them is The Simulation Theory, predominantly supported by studies in the field of neuroscience. The theory attributes the ability to recognise nuances in behaviours of others to the mirror neurons, a set of neurons responsible for simulating others’ states of mind (Rizzolatti, Fadiga, Gallese, & Fogassi, 1996). Rizzolatti and his colleagues, in a study on a macaque monkey, reported that these neurons are found to be active in the premotor cortex of the brain when the monkey executes an action and perceives the same actions executed by another monkey. The group of neurons was given the name of mirror neurons due to their imitative quality. Rizzolatti’s groundbreaking discovery became a basis for a plethora of studies in neuroscience, cognitive science, and other related fields, including music cognition (for review, see Molnar-Szakacs & Overy, 2006). After decades of research and debate on this mechanism, researchers suggested that mirror neurons are responsible for important functions of ToM such as allowing individuals to predict and imitate someone else’s actions, make sense of others’ intentions, promoting understanding of another person’s visual and conceptual vantage point, fostering self-awareness, and comprehending and expressing abstract thoughts (Gallese & Goldman, 1998; Ramachandran, 2011; Rizzolatti & Craighero, 2004). Nevertheless, the degree to which mirror neurons are responsible for these mechanisms is still unknown (see Hamilton, 2013)

Physical imitation is tied closely to ToM and Mindblindness; according to Vygotsky’s social learning theory (Vygotsky, 1978), humans make sense of the world and otherness through imitating others and reciprocating actions. Through observational work performed by a number of researchers (e.g. Abravanel, Levan-Goldschmidt, & Stevenson, 1976; McCall, Parke, & Kavanaugh, 1977), human infants rely on imitating not only vocal utterances but also actions and object manipulation as primary methods of learning.

Individuals with ASD are naturally less likely to imitate actions of various forms and purposes compared to typically developing individuals (Jones & Prior, 1985; Wurm & Schubotz, 2018). Imitation delay has been commonly revealed by studies that rely on parental reports (e.g. Ornitz et al., 1977) as well as observational strategies (e.g. Zwaigenbaum et al., 2005). DeMeyer et al. (1972) conducted a study based on a do-as-I-do method and noted that Autistic children were impaired in their imitation skills; further, those who received extensive training in action imitation preceding the experiment still failed the imitative tasks. This reveals that the problem underlying the deficit is more complicated than task difficulty and familiarity. Williams, Whiten, and Singh (2004) reviewed studies on imitation skills in ASD; the literature suggests that the deficit is considerable and is more apparent in younger individuals.

The relationship between ToM deficiency and impairment of imitation can be explained by the Broken Mirror Hypothesis: a theory which attributes the impaired ability to predict, understand, and imitate others to the deficit of the mirror neuron system (Perkins, Stokes, McGillivray, & Bittar, 2010; Ramachandran & Oberman, 2006; Williams et al., 2001). As mirror neurons become activated when an individual both performs and perceives an action (Rizzolatti et al., 1996), it is proposed that actions observed are translated into motor codes that are utilised for executing those actions ourselves (Rizzolatti & Sinigaglia, 2010). Mental states underlying these actions (such as intentions and emotions) then should be received and translated into motor codes that drive our own actions; hence when the mirror neuron system malfunctions, an individual can experience difficulties in understanding others’ intentions, developing empathy, and physically imitating others’ actions (Gallese & Goldman, 1998; Ramachandran, 2011; Rizzolatti & Craighero, 2004; Rizzolatti, Fabbri-Destro, & Cattaneo, 2009). In a systematic review regarding imitation in ASD, Williams et al. (2004) suggest that individuals with ASD have a hard time imagining themselves in others’ position due to the impairment in establishing the relationship between the observed behaviour and their own neural coding for behavioural memories alike; this process is dependent upon the neural mechanisms allied to that necessary for imitation.

Evidence for the broken mirror hypothesis lies among studies that identify the link between the mirror neuron systems and high-level cognitive functions, including ToM (Molnar-Szakacs & Overy, 2006). Carr et al. (2003) illustrated the link between critical brain areas associated with action representation and the limbic system where emotions are processed. This implies that humans understand how others feel through action representation, a mechanism of the mirror neuron system, perpetuating empathy, and modulating emotional content. Williams et al. (2006) identified activity attributable to the mirror neurons in brain areas associated with ToM function when participants engage in imitative action execution; further, they reported that the activity in these areas was less extensive in ASD participants. This suggests that the deficiency in imitation can be closely associated with ToM ability and that the mirror neuron system can be, to a certain degree, responsible for the deficit.

As researchers hypothesised that the mirror neuron system could be impaired in ASD, it is important to determine whether this neural circuit can be engaged and repaired. Recent studies revealed that the representation of the mirror neuron system can be modified through training. To date, no study can accurately pinpoint a neurobiological deficit in the neural circuit, nor can they offer an effective treatment for this impairment (see Casile, 2013). However, some studies reveal possible measures to engage the system’s activities. For example, in Catmur, Walsh, and Heyes (2007), the researchers reported that short sensorimotor training such as performing and observing small finger movements could sufficiently alter the pattern of the mirror neuron response; this suggests that the mirror properties of the neural circuit are not fixed once acquired or wholly innate. Other studies also support brain plasticity following sensorimotor skill training (e.g. Catmur et al., 2008; Doyon & Benali, 2005; Draganski et al., 2004); this suggests that the mirror neuron system can be engaged by action observation, learning, and performance. Thus, this idea highlights the possible benefit of incorporating motor components and reinforcing motor imitation in treatments for individuals with disorders such as ASD.

The evidence reviewed in this section implies that ToM and imitation have an intricate neurological association. Since imitation exercises can facilitate brain plasticity and alter the pattern of the mirror neuron response, teaching imitation can potentially help individuals with ASD to develop ToM and other social communication skills.

Music, Mirror Neurons, and The Piano

Music is a unique, multi-modal element that stimulates visual, auditory, somatosensory, and motoric functions simultaneously (Huron, 2008). It has been proposed that music-making can engage brain regions that presumably contain mirror neurons, which can be useful for facilitating action imitation and other aspects of cognitive development in ASD (Wan et al., 2010). According to the Shared Affective Motion Experience model (Overy & Molnar-Szakacs, 2009), music is perceived as an intentional expressive motor act rather than an auditory signal alone. Thus, the neural circuit that involves motor control, such as the mirror neuron system, can be engaged through musical activities.

Pitch and rhythm in music can engage the mirror neuron system and reinforce imitation through sound-motor mapping (Wan et al., 2010). The concept is typically demonstrated in the Melodic Intonation Therapy for individuals with linguistic ability, where melodic and rhythmic profiles of selected musical phrases are utilised to elicit pitched vocalisation and motor responses (Albert, Sparks, & Helm, 1973; Norton, Zipse, Marchina, & Schlaug, 2009). Further, it has been suggested widely that musical emotions are created by a combination of pitch and rhythm (e.g. Huron, 2008; Zangwill, 2013); these stimuli induce subliminal facial expressions in listeners (Witvliet & Vrana, 1996). The emotional and physical responses to music are associated with the brain’s simulation mechanism; brain regions such as the human frontoparietal mirror neuron system are activated during musically evoked emotional states (Koelsch, Fritz, Cramon, Müller, & Friederici, 2006; Koelsch, Fritz, Schulze, Alsop, & Schlaug, 2005). This suggests that auditory processing is neurologically associated with higher-order brain functions.

Observation of skilled actions performed on a musical instrument can elicit responses in the mirror neuron system. In an fMRI study, Buccino et al. (2004) reported ongoing activity in the mirror neuron circuit when observing guitar chords played by a guitarist. Further, when the action was paused, the brain area involved in motor preparation became active; Buccino and his colleagues suggested that this brain area interacts with the mirror neuron system to promote imitation learning.

The evidence reviewed above suggests that the component of pitch, rhythm, and the use of skilled actions can benefit the development of imitation; these elements co-exist in piano lessons (Duke, 2012). The piano belongs to the pitched-percussion instrument family, meaning that it produces different pitches through percussive actions. This allows the player to hear a combination of pitches while performing rhythmic hand movements on the keyboard.

Compared to other instruments, the piano is also suitable for young children and musical novices due to its vivid pitch representation: each key simply corresponds to each pitch. Silarat (2020a) utilises visual-art strategies to facilitate piano pedagogy and argues that musical pitch is abstract; it is challenging to process without concrete representation. Therefore, the piano’s visual quality can simplify the process of learning, conveniently bridging the gap between the action and the goal. Studies have examined individuals with ASD’s performance on visual-related tasks in comparison to language-based activity and reported better performance (Quill, 1997) as well as enhanced task-related neural activity in regions overlapped with visual processing (Samson, 2013) in the former. Hence the visual aspect of the piano keys allows the learner to easily grasp not only the concept of musical pitches but also the skilled hand movements performed in the lesson. This can make imitation more convenient for students with ASD.

The piano keys assemble an interesting pattern that can be attractive for individuals with ASD who have a predilection towards systemising. Systematising refers to the drive to analyse, construct, predict, and control a rule-governing system (Baron-Cohen, 2002). Individuals with ASD possess the extreme eagerness to systemise, which many studies define as a talent associated with those of a savant (e.g. Baron-Cohen & Lombardo, 2017; Baron-Cohen et al., 2009; Happé & Vital, 2009). Although this concept is not usually discussed within the topic of ToM, systemising can enhance the motivation in ASD (Chevallier, Kohls, Troiani, Brodkin, & Schultz, 2012); hence they can be eager to figure out the piano patterns and imitate actions involved in the mechanism of the instrument.

Besides the hyper-systemising tendency, individuals with ASD usually display heightened interest in the sound of music (Møller et al., 2002; Parker Hairston, 1990). When participating in active listening and music-making, physiological responses can be evoked in these individuals; examples include a sense of calmness and agitation (Cook, Roy, & Welker, 2019; Mössler, Schmid, Aßmus, Fusar-Poli, & Gold, 2020). These senses can help with self-regulation in ASD, potentially resulting in a heightened interest in listening and producing musical stimuli. Further, music can substitute for the limitation in verbal expression (Heaton, 2009); thus, music-making provides opportunities for individuals with ASD to express themselves through non-verbal realms alternatively.

The attractive quality of music increases the willingness to participate in individuals with ASD (Holczer, 2018; Silarat, 2020b). Along with the use of a visually simple instrument, piano lessons can become an appropriate realm where the mirror neuron system is comprehensively engaged. It is worthwhile to note that most literature regarding music and the brain stems from the tradition of music therapy. With more studies in other contexts, practitioners and teachers can gain a deeper understanding of potential cognitive benefits from other forms of musical practice, including instrumental lessons.

From Spontaneous Imitation to Goal-Directed Imitation in Music Lessons

Spontaneous imitation is employed for social purposes in typically-developing individuals (Meltzoff & Moore, 1977) and is motivated by the facial expressions of others (Kampe, Frith, Dolan, & Frith, 2001). Within a musical context, Stephens (2008) reported increased spontaneous imitation in four neurotypical children throughout a musical segment (accompanied by background music, dancing, and instrumental playing) compared to a non-musical segment. This suggests that spontaneous imitation can potentially be enhanced under musical circumstances. Nevertheless, the lack of the need for social approval in ASD might perpetuate diminished spontaneous imitation in various contexts (Roeyers, Van Oost, & Bothuyne, 1998; Whiten & Brown, 1998). This means that the natural tendency that individuals with ASD will imitate and reciprocate actions can be largely reduced (see Van Etten & Carver, 2015). In music lessons, teachers should understand the developmental condition of the student in order to form appropriate expectations.

In piano lessons, students with ASD might not understand the facial expressions that signify when and why imitation should occur. Vivanti et al. (2014) discovered three insightful pieces of information: individuals with ASD imitate less frequently than standard learners, they tend to employ emulation more than imitation, and they tend to observe the action of the to-be-imitated agent rather than their facial expressions. Therefore, it is more difficult for students with ASD to employ spontaneous imitation simply by interpreting the inviting gesture of the teacher (expressed through body language and facial expression).

The pattern of imitation in ASD can be explained by the goal-directed theory of imitation (GOADI) (Bekkering, Wohlschlager, & Gattis, 2000; Wohlschlager, Gattis, Bekkering, Frith, & Wolpert, 2003), which suggests that the observer cognitively decomposes each observed action into a hierarchy of goals; in this case, the goal is more important than the action itself. From the perspective of a piano teacher and music educator, Holczer (2018) suggests that students with ASD tend to imitate when the given task is goal-directed and meaningful. This scenario is congruous with Hamilton, Brindley, and Frith (2007), which assessed goal-directed imitation, grasp planning, and mirror imitation and reported no difference in performance between ASD and neurotypical participants. Further, the brain regions described as the mirror neuron system are involved in goal-directed imitation (Iacoboni, 1999; Koski et al., 2002) as well as motor planning (Johnson-Frey, Newman-Norlund, & Grafton, 2005). Wild, Poliakoff, Jerrison, and Gowen (2012) suggest a similar concept; participants with ASD relied on goal-directed strategies for imitation, even when the visual goals were absent.

Piano teaching can become an activity that reinforces physical imitation due to its goal-directed nature. Piano teachers in Silarat (2020b) reported that making the goal explicit and literal helped reinforce the achievements of tasks and imitations during the teaching process. Nevertheless, even without the emphasis on the goals, students with ASD can display fixate interest in a specific type of sound and harmony (Holczer, 2018); this scenario is associated with ASD’s natural obsession with repetitive, technical details (Mottron, Dawson, & Soulie`res, 2009; Stocco, Thompson, & Rodriguez, 2011). Hence musical elements such as sound, harmony, and technical rhythm can be considered attractive products of learning for students with ASD. These products can function as musical goals and can reinforce imitation indirectly by provoking the students’ curiosity and heightening their eagerness to complete the task.

While there is a limited amount of studies and literature that investigate how exactly individuals with ASD react to musical stimuli in the context of real-life music teaching rather than in a laboratory setting, Holczer (2018), who documented her experience teaching piano to students with ASD, reported several observed scenarios where students with ASD displayed obsession towards musical stimuli and tried to reproduce them repetitively. This pattern motivated these students to imitate the teacher’s actions and develop the control of their muscles through repetition. Holczer also explained that the finishing products that are attractive to these students extend beyond the duration of sound; the pitch height, timbre, and harmony are also elements that capture the students’ attention and motivate them to imitate the teacher’s actions repetitively. 

Object Imitation and Social Interaction in Piano Lessons

Individuals with ASD perform imitative actions more competently with objects compared to movements through gestures pantomime (Rogers, Hepburn, Stackhouse, & Wehner, 2003). Simple actions that are not object-directed are associated with social intention and communication (Uzgiris, 1981); hence, these behaviours can be challenging to imitate for students with ASD. However, imitation in ASD takes place when these individuals explore the surrounding environment (Ingersoll, 2008); therefore, in piano lessons, they are likely to imitate actions on the keyboard in order to make sense of the immediate context. The setting where children with ASD can touch and see the object is also favourable towards their imitation skills; Libby, Powell, Messer, and Jordan (1997) posits that children with ASD have a particularly difficult time imitating pretend acts that involve imaginary objects. This is congruous with Baron-Cohen (1989), which suggests that individuals with ASD have a hard time distinguishing between the object and the thought of it.

It has long been noted that object-oriented imitation is employed for social purposes in many cases (e.g. Eckerman & Stein, 1990; Uzgiris, 1990). Mueller and Lucas (1975) suggest that performance on the same object perpetuates the initiation of interaction between infants. Further, two studies (Ingersoll & Schreibman, 2006; Stone, Ousley, & Littleford, 1997) revealed that the use of spontaneous pretend-play increased after teaching participants with ASD to imitate actions on objects. These studies emphasise the correlation between object imitation and play skills, which suggests that physical imitation and higher-order functions such as ToM are related to a certain degree. However, Rogers et al. (2003) illustrates the dissociation between assessment of object imitation and play skills when controlling for developmental age, which suggests that the relationship between these two domains can be mediated by developmental age and other existing factors.

Imitations arose in piano lessons are accompanied by constant social interaction between the teacher and the student. When the student imitates an action and produces a musical phrase, the teacher usually responds by providing feedback; this can lead to turn-taking and communication (Silarat, 2020b). Moreover, music-making can also improve joint attention skills in ASD (Kim, Wigram, & Gold, 2008). Therefore, the act of teaching and learning music through imitation can potentially facilitate joint attention in ASD in a similar manner.

Piano lessons can become a venue where object imitation and social interaction skills are nurtured simultaneously. Imitative tasks during piano lessons can be favourable towards students with ASD due to their goal-directed and object-oriented nature. With more research, these tasks can potentially be adapted to intentionally reinforce the imitation skills in ASD and potentially nurture other forms of imitation, allowing these individuals to develop ToM and acquire social communication skills in piano lessons.

The One-On-One Learning Context

Some may argue that rote learning in group settings can reinforce imitation; while that is undeniably true, such context might not be beneficial for students with ASD. Music educators such as Jaques-Dalcroze (1967a1967b) and Suzuki (1993); Suzuki & Nagata (1999)) posits that rote learning can bring about the most natural way of understanding musical elements; further, children should develop an aural perception of music prior to learning musical notations. While music education approaches that encompass rote learning and rhythmic components are believed to facilitate synchronisation and imitation in young children (Wedin, 2015; Willour, 1969), it is questionable whether these approaches are suitable for individuals with ASD, whose social communication and imitation skill are originally impaired.

The reduced spontaneous imitation and the need for explicit goals in ASD perpetuate the difficulty in functioning in group settings. Within the group, students with ASD receive fewer opportunities to participate in typical turn-taking activities that facilitate later communication and academic skills (Carpenter, Pennington, & Rogers, 2002). Therefore, the setting where imitation skill is scaffolded deserves a considerable amount of attention, no less than the method of the intervention itself.

For some students with ASD, a one-on-one piano lesson might be a more suitable venue to reinforce imitation compared to group settings. This can be due to the difficulties in their social functioning (Izuma, Matsumoto, Camerer, & Adolphs, 2011), limitation in expressive language use (Carter, Williams, Minshew, & Lehman, 2012), and overstimulation (Jordan, 1999). In a one-on-one piano lesson, the distraction from peers and surrounding stimuli is removed. The teacher receives the opportunity to focus on one student. When full attention is given, the instructor can perform a careful assessment of the student’s learning strengths and weaknesses as well as their imitative capacities. Following the assessment, the teacher will then proceed to personalise their own instruction; this allows for real-time adaptation during the teaching process.

Despite arguing that a one-on-one music teaching context can provide a suitable environment for students with ASD, group music therapies and interventions that are empirically supported shall not be disregarded in any manner. This section merely suggest that piano lessons can also serve therapeutic purposes. This case, the learner can develop cognitive functions while receiving opportunities to achieve musical milestones.


The evidence reviewed suggests that piano lessons can become a potential medium where children with ASD develop ToM through imitative tasks. Throughout the lesson, students with ASD will be continuously exposed to a wide range of musical stimuli that engage the mirror neuron system, which can be beneficial for motor-related task performance. Apart from the ability to stimulate crucial brain regions, music can become a natural motivator for individuals with ASD and heighten their interest during the lesson; this can potentially lead to increased interaction between the teacher and the student. Further, the goal-directed nature of music teaching and the opportunities for scaffolding can perpetuate an increase in imitative actions.

Two main limitations in the literature arose from this review. Firstly, the exact mechanism and functions of the mirror neuron system have not yet been identified (see Hamilton, 2013); consequently, the link between motor-coding and higher-order functions has not been made explicit (see Casile, 2013). It is difficult for practitioners to pinpoint exactly how to facilitate ToM, considering that multiple theories underlying its mechanism were proposed (see Henderson, 1996; Livingstone & Thompson, 2009). Second, the literature in the area of musical pedagogy, particularly studies that reflect insights about the teaching process in a real-life context, is sparse. Studies that explore piano pedagogy and students with developmental disorders are increasing, predominantly in the form of thesis and dissertation (e.g. Davis, 2019; Mullins, 2017). This signifies that there is an increased interest in musical pedagogy for disabled individuals in society. However, studies that examine the therapeutic quality of piano teaching are still lacking, leading to an unclear link between music lessons and therapy. More studies conducted by practitioners in the field of piano pedagogy should be conducted and published in order to bridge the gap and provide a stronger foundation for an alternative form of service offered to individuals with ASD.

Throughout the journey of exploring different forms of service and interventions, it is essential to note that no single approach is, across time, the best for all individuals with ASD (Volkmar, Lord, Bailey, Schultz, & Klin, 2004). After all, it is possible to consider an approach that nurtures a variety of skills suitable for each individual’s cognitive capacity and builds the bridge between their inner and outer world (Scott, 2016). As research on this topic continues to develop, practitioners will gradually be equipped with a deeper understanding of musical instructions for students with ASD and the potential impact on their cognitive development, leading to making informed decisions for choosing teaching methods and therapeutic approaches for each of these individuals.

Chomchat Silarat
Published online: 19 Jul 2021