Massage efficacy in the treatment of autistic children – a literature review

Abstract

Autism is one of the most serious contemporary medical problems. The causes of this disorder remain unknown however there are many hypotheses on the development of this specific symptom constellation. Autistic children have difficulties with contact establishment, they do not like to be touched and do not react to the external stimuli. Studies show that emotional, social, and cognitive development of an autistic child depends to a large extent on his/her early tactile experiences. Therefore it seems that effective treatment methods should be sought in this area. These methods include various tactile therapies, predominantly massages. The purpose of a massage is to induce physiological reactions in the body that have preventive, therapeutic, and relaxing effects. The purpose of this work was to present selected massage forms as supportive rehabilitation methods of autistic children. Massage forms were selected that show high effectiveness in relieving autism symptoms. The results of clinical studies by various authors prove that massages reduce child’s anxiety, improve social communication, and favor formation of closeness and bonds with the parents thus bringing the prospects for better development of the child.

Introduction

Autism is a developmental disorder which, according to the estimates of the SYNAPSIS foundation, affects about 20 thousand children and adolescents aged under 18, and at least the same number of adults [in Poland] (www.synapsis.waw.pl/images/stories/poradnictwo/raport_2006.pdf, 19.06.2007r.). Centers of Disease Control and Prevention in the USA report that the disorders from the autism spectrum are diagnosed in about one in 68 children (Baio 2014). The term ‘autism’ was introduced by Bleuler in 1911 and denoted one of the axial symptoms of schizophrenia. Bleuler defined autism as ‘a closure in one’s inner world and loosening of the discipline of logical thinking’ (Yates and Le Couteur 2009). In 1943, Kanner, a psychiatrist, was the first to introduce autism as a separate diagnostic category by reporting 11 cases of children with such symptoms, among others, as: disturbances of verbal communication or stereotypical behavior. Autism is one of the most serious contemporary medical problems and thus it is a frequent subject of discussion in medical, psychological, and psychotherapeutic circles. Autism is not a disease but a syndrome resulting from many genetic and non-genetic causes. Autistic children have an increased or decreased sensory response in one or more of the five basic senses (sight, hearing, smell, taste, and touch) but they may also be hypersensitive with respect to the general body awareness, body position, posture, movement, and balance (Cullen and Barlow 2002). Many therapies are used in children with autism nowadays, however this syndrome is incurable (Muhle et al. 2004; Plauché and Myers 2007). In relation to the fact that the causes and the pathomechanism of autism are unknown, the specialists suggest many forms of autistic symptoms alleviation. The parents of autistic children search for therapies that promise improvement of a child’s condition and the doctors must find a balance between excessive criticism and passive acceptance when choosing the optimal treatment method (Hughes 2008). What is known for sure, is that increased awareness and early diagnosis may provide the child with good development conditions and alleviate his/her symptoms (Waś et al. 2011). Positive results in alleviation of the symptoms of autism should be sought in the field of physiotherapy, specifically in various forms of massage (Lee et al. 2011).

Aim of the study

The purpose of this study was to present selected forms of massage as supportive methods with respect to a comprehensive program of rehabilitation of autistic children, particularly alleviating the symptoms of this syndrome. Massage forms were selected that show high effectiveness in relieving autism symptoms. Our work is a narrative review based on a search of the world’s scientific literature. Because of a low number of publications found in databases the authors have decided not to perform a formal systematic review.

Behavior of autistic children

The first signal of the autistic syndrome is a disturbed relation between the mother and the child. The infant has wandering eyes and cannot fix them on his/her mother and does not react to signals from the mother as well as to the external stimuli. One of the main symptoms is a so called ‘stiffness’ in response to an attempt to hug the child that is a defense against a physical contact (Chawarska et al. 2009; Waś et al. 2011). The stereotypic behavior of autistic children that appears in their first few months of life includes moving the fingers closely to the eyes and turning hands. Autism development may be accompanied by appetite and sleeping disturbances. The most characteristic clinical symptoms of autism in children aged 2–3 include the inability to establish social communication and speech disturbances. The external world seems to be outside of the area of a child’s interest (O’Hare, 2009).

Older children do not play with their peers and do not establish any bonds with them. They play stereotypically, e.g. they order things in a row always in the same sequence or they repeatedly activate mechanical toys (Levy et al. 2009). Autistic children are frequently affected by speech disturbances. These children stop in their development at the stage of a so called ‘cooing’ and they may start to produce single words or simple sentences at the age of 4–5. They have problems with communication and such symptoms appear as echolalia (a thinking disorder that manifests itself as purposeless repeating of words or phrases spoken by other people) and pronoun misuse (using ‘you’ instead of ‘I’) (O’Hare 2009).

Autistic children are often indifferent to other people and treat people as inanimate objects. They cannot maintain a dialog and have a need to keep their environment unchanged. Sometimes these children cannot cope with situations that pose no difficulties to their peers and at the same time they solve complicated problems or express unusual talents in other tasks (they show extraordinary memory, arithmetic, plastic or musical abilities). However, only 5–15% of autistic people do have these abilities (Llaneza et al. 2010).

Review of selected massage forms proposed in the treatment of autism

Early diagnosis is of key significance in the rehabilitation of autistic patients, however a selection of appropriate therapeutic methods in the treatment of these patients seems to be most important here. The therapists may choose from a wide range of techniques, including various forms of massage. There are many types of massage, differing with respect both to the technique and to their effect on the body. The effect of massage on the body may be considered in the light of several mechanisms: physiological, informational, mechanical, or energetic reactions (Marszałek 2009). Therapeutic massage is defined as manual deformation of soft tissues of the body to improve the health condition and well-being of the patient (Sherman et al. 2006). When performing massage, a child’s individual sensitivity and his/her general health condition should be always kept in mind. Besides the therapeutic massage many other types of massage are applied in the treatment of autism, including the more and more popular oriental types of massage. Presented below are the forms of massage that according to the subject literature may show a high efficacy in relieving the symptoms of autism. These are as follows:

Shantala massage

Shantala massage is a traditional Indian massage technique for infants and children, described and introduced into the European ground by a French obstetrician, Leboyer (2012). The main technique of Shantala massage is superficial caressing causing elastic deformation of the epidermis and of the papillary layer of the dermis. This procedure supports the development of the sense of touch, increases the awareness of child’s own body, enhances the feeling of safety and improves bonds with the parents. It also stimulates the endocrine system and the work of superficial and deep sensation receptors, and regulates sleep (Wilk 2015).

Traditional Thai massage

The Thai massage originates from India, and at the philosophical level it is associated with Buddhism and Ayurveda. This massage method includes maneuvers similar to those used in the classical massage, such as caressing, rubbing, kneading, and similar passive movements of which the purpose is to stretch the muscles and tendons and to increase the joint mobility, tractions, and other movements from the spectrum of joint mobilization and pressure exerted on the biologically active points in the course of energetic channels. The advantages of the Thai massage are the following: accelerated circulation of blood and lymph, and thus better oxidation and hydration of the tissues, as well as relaxation and improved elasticity of muscles (Wiwanitkit 2010).

Aromatherapeutic massage

The aromatherapeutic massage, also called the ‘scent’ massage is a procedure done with the use of essential oils that combines the healing power of touch with specific properties of the oils. This type of massage is the most important aromatherapeutic method because it is the most effective way of introduction of the essential oils into the body (Nawrocka and Ślężyńska 2010).

Tibetan bowl sound massage

The type of massage with the sound of Tibetan bowls is a specific form of sound—the vibration therapy. Sound energy improves the vital processes of the body. The stimulus of the specific sound is a sound massage of the entire body and of its tiniest structures. Resonance stimulation of biological oscillators enhances the blood and lymph flow and decreases muscle tension in the body. This creates favorable conditions for revitalization of biological processes in the cells and for enhancement of inherent healing forces (Hess 2013).

Review of the studies on the use and efficacy of massage in the treatment of autistic children

The studies show that emotional, social, and cognitive development of a child depends to a large extent on his/her early tactile experiences. Only numerous and positive sensory experiences allow the child to develop abilities of touch recognition. Autistic children have difficulties with contact establishment, they do not like to be touched and they do not want to be hugged as early as in their infancy. In theory, when the sensory system is immature and does not work properly, abnormal neuronal signals are sent to the cerebral cortex. Such a situation may interfere with a given person’s organization of their behavior and it disturbs concentration. It. may also lead to a negative emotional reaction to tactile stimuli (Paczkowska and Szmalec 2014).

The study by Escalona et al. (2001) has confirmed a significant effect of therapeutic massage performed by the parents of a child. Twenty autistic children aged 3–6 took part in a one-month experiment. Half of these children had a 15-minute massage session done by their parents before going to bed. In the control group, the parents did not touch the children before going to bed but they read books to them. After the experiment, the children in the massage group showed a better social cooperation and a reduction of stereotypical autistic behavior. In the study by Tsuji et al. (2015) on seven autistic boys aged 8–12, their mothers performed a 20-minute massage session each day for a period of three months. Saliva was collected from the mothers and their children before the start of massage, after one massage session, after three months of massage and after four months from the completion of the treatment. The oxytocin level was measured in the saliva samples with an immunoenzymatic assay. The oxytocin level changes from baseline observed after one massage session were not significant, however after the entire period of the massage therapy both the children and their mothers had higher oxytocin levels compared to the period before the massage started. The increased levels of oxytocin, frequently called ‘the hormone of love’, had a favorable effect on the emotional relation between the mother and the child. After the massage, three mothers reported that their children were more relaxed and four—that their children improved their communication with other people. Six mothers reported that they felt closer to their children. Five mothers said that they were satisfied with the therapy and that their children were happy with the massage. This suggests that autistic behavior of children may be corrected with a tactile therapy in the form of massage. A significant relationship between the development of cognitive abilities and the use of massage in four-month-old infants was also found by Cigales et al. (1997). Vlaskamp and Nakken (2008) have proved that tactile stimulation in children with autism and mental retardation improves their intestinal peristalsis and calms them down.

Other studies were related to children with an abnormal function of the sense of touch, and a lower severity of behavioral and linguistic abnormalities related to autism. The effect on the children was of a two-way nature: the therapists worked directly with the children 20 times during 5 months and the parents performed a 15-minute whole body massage of their children every day before their going to bed. The improvement was assessed in the nursery school (by the teachers) and at home (by the parents). Faster and lighter tapping techniques were used at the beginning of the therapy, and more gentle maneuvers were applied in the tickle areas. The assessment by the teachers and the parents showed that the children treated with massage made a significant improvement in their social and linguistic abilities. The same assessment also showed a reduction in the children’s autistic behavior, as compared to the control group. The achieved improvement was stable for 10 months after the study, which pointed to quite durable changes in the studied children (Silva et al. 2011).

Many authors all over the world have verified the effect of the Shantala massage on autistic children. Felisbino et al. (2012) have shown in their studies that the children slept better after such massage as well as that the median oxygen saturation level increased in these children. Cullen and Barlow (2002) have examined 12 autistic children aged 3–13 who received Shantala massage treatment performed by their parents for eight weeks. The parents of these children were interviewed directly before the massage sessions and after their completion. The pre-massage interviews assessed the importance of touch between the parents and the children, as well as their motivation for participation in the study. The interviews conducted after the program completion examined the parents’ experiences based on Shantala massage and the effect of this massage on their relations with their children. At the end of the program, one of the mothers had noticed that her child tolerated touch much better than before the program and that he/she was more relaxed. During the interview, she said that the tasks requiring physical contact such as the child’s getting dressed, as well as dressing and undressing the child had become easier, possibly due to the improved child’s tolerance to the touch. Two other parents had similar observations. After the treatment one of them perceived his/her child as being calmer. This result was considered positive because previously the child had reacted very nervously to the majority of the situations that he/she was involved in. The other parent noticed some improvement in verbal communication and reduced weepiness of his/her child. The interview with another parent revealed that his/her child brought or pointed to a massage oil bottle during the day, before going to bed or during the car journey, which probably meant asking for a massage. A massage, involving only hands, performed in the car significantly facilitated journeys with the child who was previously very agitated and stressed by traveling by car. All the parents taking part in the study admitted that the possibility to get closer to their children made them happier.

Also in the study by Michalczak et al. (2014), the effects of Shantala massage in the subjective assessment of the feelings of the parents of infants were considered to be very favorable. The authors concluded that the effect of the massage therapy was significant in calming and relaxation of the infants, and that it improved their ability to fall asleep and their sleep quality in general. This was probably related to the activation of the pituitary—hypothalamic axis and normalization of cortisol secretion that was suggested in a study by Gunnar (1992). Normalization of the circadian cortisol secretion rhythm as a result of Shantala massage in infants was also observed by Fogaca et al. (2005).

The study by Piravej et al. (2009) with the use of traditional Thai massage included 60 children with ASD aged 3–10. Each of them participated in sensory integration therapy (SI). This therapy, called ‘scientific play’ had to combine playing, i.e. swinging, skateboarding, cradle, with integration of sensory stimuli and experiences flowing to the central nervous system. Besides the SI therapy, the children from the study group received a traditional Thai massage that was performed twice a week for eight weeks. The analysis of the results during the last week of the experiment showed a significant improvement in both the study and the control groups. The parent-reported assessment showed a significant improvement in the children’s sleep quality. The massage group had better results with respect to anxiety elimination and behavioral problems.

There is no direct evidence of favorable effects of Tibetan bowl sound massage on autistic children but researchers recommend its use for physical (use of sounds with domination of low tones) and psychical (use of high tone sounds) relaxation. There is also an opinion that massage with Tibetan bowl sounds may decrease muscle tone, reduce the level of stress hormone secretion, reduce pain sensation, and harmonize breathing rhythm (Hess 2013).

In case of aromatherapy massage, its favorable effect on falling asleep and sleep as well as on the mood of autistic children was shown. Fragrances considered as pleasant (e.g. lavender) or having a potential effect on the nervous system (e.g. melissa) were used in the majority of studies (Fung et al. 2012).

Conclusions

For over half a century autism has been a big problem for psychologists and doctors of various fields of medicine. The genetic background of autism is a frequent subject of research but no clear or definitive solutions have been made in this field so far. There is no effective treatment method of autism but some available techniques may alleviate its typical symptoms. The primary purpose of any treatment in an autistic child is a reduction of the anxiety level—unless this is achieved any attempts to teach such a child are doomed to failure. Other activities in the upbringing of an autistic child include expanding a child’s ability to communicate and realization of the developmental potential of the child according to his/her predispositions (Turner et al. 2006). Clinical studies show that various types of massage reduce a child’s anxiety, improve his/her linguistic abilities and social communication, and increase his/her tolerance to touch; when an autistic child’s tolerance to touch increases, his/her aggression and anxiety diminishes. These issues are very extensive and interesting thus they are worth being addressed and studied by other researchers. It seems reasonable that further experiments are based on a collection of the data concerning the effect of massage on the autonomous nervous system (Escalona et al. 2001; Silva et al. 2008; Piravej et al. 2009). The increased interest in various massage techniques in the recent years is related to the general trend for a wider use of these techniques in healthcare. One should bear in mind that massage must be performed by a specialist in order to avoid the adverse effects. There is an opinion that oriental massage techniques are nowadays important in the treatment of children affected by autism. The effects of these techniques on a child’s body create conditions that promote achievement of harmony and perfect physical, mental and spiritual health, and of balance between these levels (Murawow et al. 2010). The massage techniques presented in this study provide good therapeutic effects. Observations made to date suggest that these methods are effective and safe. This conclusion needs to be confirmed in further studies.

Funding

No funding was received.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Conflict of interest

No potential conflict of interest was reported by the authors.