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Effects of Thai Traditional Massage on Autistic Children's Behavior

Article  in  Journal of alternative and complementary medicine (New York, N.Y.) · December 2009
DOI: 10.1089/acm.2009.0258 · Source: PubMed

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THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 15, Number 12, 2009, pp. 1355–1361
ª Mary Ann Liebert, Inc.
DOI: 10.1089=acm.2009.0258

Effects of Thai Traditional Massage on Autistic


Children’s Behavior

Krisna Piravej, M.D.,1 Preeda Tangtrongchitr, B.Sc.(Pharm), M.Sc.,2 Parichawan Chandarasiri, M.D.,3
Luksamee Paothong, M.D.,1 and Saengaroon Sukprasong, B.Sc.4

Abstract

Objectives: The objective of this study was to access whether there were any therapeutic effects of Thai Traditional
Massage (TTM) on major behavioral and emotional disturbances in Thai autistic children.
Design: This was a randomized controlled trial study.
Settings=location: The study was conducted at the Rehabilitation Centre of the Thai Red Cross Society.
Subjects: A total of 60 autistic children between the ages of 3 and 10 completed this study.
Interventions: Standard sensory integration therapy (SI) was compared to the SI with TTM treatments.
Outcome measures: Parents and teachers assessed major behavior disturbances using the Conners’ Rating Scales
at 0 and 8 weeks. Sleep Diary (SD), recorded by the parents, assessed the patient’s sleeping patterns every week.
Results: Sixty (60) autistic children, mean age 4.67  1.82, were recruited. No statistical differences were seen in
the demographic and baseline data among both groups. From both the Conners’ Teacher Questionnaire and SD,
statistical improvement was detected for conduct problem, hyperactivity, inattention-passivity, hyperactivity
index, and sleeping behavior. However, results from the Conners’ Parent Questionnaire revealed an improve-
ment only for anxiety ( p ¼ 0.04) in the massage group, whereas when both groups were compared, a significant
improvement in conduct problem ( p ¼ 0.03) and anxiety ( p ¼ 0.01) was found. Results indicated that TTM may
have a positive effect in improving stereotypical behaviors in autistic children.
Conclusions: Over a period of 8 weeks, our findings suggested that TTM could be used as a complementary
therapy for autistic children in Thailand.

Introduction For example, sensory integration therapy (SI) uses the


child’s intrinsic motivation to help change the child’s adaptive

I n recent years, autism spectrum disorders have received


increased attention in youngsters. The number of individ-
uals diagnosed with autism has dramatically increased in the
response by utilizing a wide variety of play media, activities,
and=or equipment to stimulate sensory integration.11 This
process occurs at the neuronal cellular level where many parts
past few years. Similarly, in Thailand, autism has also become of the nervous system work together to allow the person to
a more commonly diagnosed childhood brain disorder. It was interact with the environment effectively and experience ap-
found that 4.4 of 1000 Thai children were prone to be autistic, propriate satisfaction.12 At each session, the therapist will
and the prevalence rate has been 9.9 children per 10,000 select a sensory agent that has either a facilitatory or an inhib-
populations.1 These patients typically demonstrated prob- itory effect on the child’s nervous system that will target
lems in behavior and were less effective communicators. certain adaptive responses such as reflex integration, adequate
Interestingly, no single cause has been identified for the postural adjustments, movement successes, increased alert-
development of autism.2–7 Presently, since neuropsychologi- ness and awareness of input, self-regulation without mala-
cal etiology is essentially unknown,8,9 it is difficult to treat daptive emotional reactions, and abilities to start and
autism from a pharmaceutical standpoint.2,3,10 This situation participate in the task through to completion.13 This technique
has created a demand for nonpharmaceutically based treat- has been shown to help decrease tactile and other sensitivities
ments and has led to the development of treatment method- to stimuli known to interfere with the children’s ability to
ologies in a wide variety of fields. play, learn, and interact.14,15

Departments of 1Rehabilitation Medicine and 3Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
2
WATPO Thai Traditional Medicine and Massage School, Bangkok, Thailand.
4
Rehabilitation Centre, Thai Red Cross Society, Samuthprakarn, Thailand.

1355
1356 PIRAVEJ ET AL.

Other new approaches have emerged to improve sociali- based on the Diagnostic and Statistical Manual of Mental
zation and learning abilities of these patients.2,9,16,17 These Disorders (DSM IV) criteria. In Thailand, diagnosing children
interventions are starting to involve the parents of the patients with autism based on the criteria of DSM IV is acceptable.21
in the therapeutic sessions. In addition, some of the skills used Parental or guardian consent was obtained from each par-
by the occupational therapists are being transferred to the ticipant prior to starting the study. The exclusion criteria
parents such as massages or touch therapies so they can con- included contraindications for TTM such as hematological
tinue administering these techniques at home at their own disorders, fractures, arthritis, joint dislocation, fevers, car-
convenience.18 diovascular, and pulmonary diseases. Additional exclusion-
It has been reported that tactile stimulation in the form of ary criteria included the inability to complete 80% of the
massage could reduce stereotypical behavior and touch aver- treatment program or receive a total of 13 massage sessions.
sions as well as improve sleep disturbance, classroom con- Patients with noncooperative parents or guardians were ex-
centration, and social interactions.19 Another study showed cluded to avoid patients lost to follow-up or withdrawals. As
massages delivered by the parents significantly improved per Good Clinical Trial practices, all patients were informed
sleep and enhanced behavior control in preschool autistic that they could withdraw from the study at any time without
children.20 Likewise, Cullen-Powell et al. (2005) demonstrated losing any current health care benefits from the Centre.
that massage therapy was able to calm and relax autistic
children enough to pay attention to classroom activities.18 Randomization and assessment tools
Though these initial evidences are encouraging, the number of
The participants were randomized into the control and
studies is still scarce and warrant further studies in this area.
massage group via block randomization. This technique
Of note, Thai Traditional Massage (TTM) has never been
randomly allocates permutations of treatments within each
studied in autistic patients even though Thai massages have
block, maintaining the same size for each group.
been used frequently as an alternative therapy dating back
The parents were not blinded in accordance with local IRB
more than 2500 years ago. This technique has been tradition-
guidelines, but the teacher (occupational therapist) was blin-
ally attributed to Shivaga Komarapaj, the Lord of Buddha’s
ded. After the patients were randomized, the parents and
doctor and the Father of Thai Medicine. The Thais have
teacher were required to fill out the Conners’ Parent Rating
combined Indian yoga with Chinese acupressure, resulting in
Scales (CPRS)22 and Conners’ Teacher Rating Scales (CTRS)22
a unique Thai style massage. It is noteworthy that TTM does
on day 0 and at the end of week 8, respectively. Aside from
not concentrate on the muscles but focuses on the entire
that, the parents were also required to record their autistic
physical body by manipulating invisible channels and energy
children’s sleeping behaviors every week in the Sleep Diary
bodies known as auric body. By applying pressure to vital
(SD).23 Assessment using the SD has been shown to be ef-
points along these channels, the therapist’s internal energy is
fective in identifying improvement in sleep disorders in au-
used to boost and stimulate the flow of the patient’s internal
tistic children.24 At week 8, both groups were re-evaluated
energy, and direct it toward the patient’s ailing organs and
using the same questionnaires from day 0 (Fig. 1).
glands. Hence, TTM is considered to be both spiritual and
therapeutic. For this reason, we wanted to investigate whe-
Clinical interventions
ther this alternative therapy, TTM, can be used to improve
behavioral and emotional disturbances in Thai autistic chil- Both the control and massage groups received SI by the
dren in combination with SI. same occupational therapist, 2 sessions per week, 1 hour per
session, for a duration of 8 weeks, for a total of 16 sessions.
Materials and Methods For each child, the therapist created an appropriate and in-
dividualized therapeutic environment. The sessions utilized
Participant selection
The study protocol was approved by The Institutional
Review Board of the Faculty of Medicine, Chulalongkorn
University, Bangkok, Thailand. This was a randomized,
controlled clinical trial comparing the effects of TTM, a behav-
ioral intervention, with SI in Thai autistic children between
the ages of 3 and 10 who were recruited from the Re-
habilitation Centre of the Thai Red Cross Society. This Centre
received referrals from several doctors from different hospi-
tals located throughout Thailand and hence was the perfect
venue for us to recruit our participants.
A total of 60 autistic children were enrolled in the study and
were randomized into two groups: massage group (n ¼ 30)
and control group (n ¼ 30). The control group received only
SI, whereas both SI and TTM were administered to the mas-
sage group. The preferred and ideal treatment for the mas-
sage group should only be TTM, but since this procedure has
never been studied in autistic children, the local Institutional
Review Board (IRB) prohibited its use unless it was accom-
panied with SI. Each participant was required to have a FIG. 1. A randomized controlled trial Consolidated Stan-
definite diagnosis of autistic disorder made by a psychiatrist dards of Reporting Trials (CONSORT) flow diagram.
EFFECTS OF THAI TRADITIONAL MASSAGE 1357

the following key principles of SI: (1) Just Right Challenge,


(2) The Adaptive Response, (3) Active Engagement, and (4)
Child Directed.15 For the ‘‘Just Right Challenge,’’ the thera-
pist created playful activities that were slightly challenging
but easily accomplished by the child. This approach balanced
the abilities of the child with the challenges given. As for
‘‘The Adaptive Response,’’ the therapist observed the child’s
ability to respond and adapt to the ‘‘Just Right Challenge’’
activities. In order to reinforce the new behavior, more ac-
tivities were given.
Next, for the ‘‘Active Engagement,’’ the therapist contin-
ued to challenge the child with artful, creative, playful,
sensory activities to entice the child to incorporate new and
advanced abilities. This enabled the child to ‘‘learn how to
learn’’ by incorporating a variety of activities that targeted
specific sensory deficits. These activities incorporated ves-
tibular integration, proprioceptive and tactile stimulation. A
planned activity schedule was inserted into the child’s nat-
ural environment. Last, for the ‘‘Child Directed,’’ the thera-
pist followed the child’s lead or suggestions in creating more
sensory-rich activities to develop a higher cognitive level and
motor functions. All of these activities also included the
child’s caregivers and other relevant professionals.
The second intervention used was TTM. Only the massage
group received TTM treatments in addition to SI. To avoid
variations in the massage technique, only one masseuse was
employed to deliver the massages to all patients in the inter-
vention group. First, pre-massage rapport was done prior to
the session to reduce the patient’s anxiety or fear. Building
rapport with the patient prior to the massage treatment sig-
nificantly enhanced the patient’s cooperation and willingness
to be massaged. After that, the child was instructed to lie
down, facing upward while the massage was administered.
The masseuse applied some pressure to the sole of the foot for
a few minutes before moving to the foot, leg, thigh, hand, arm,
and fingers. Next, the child changed positions by lying on one
side of the body. The foot, leg, thigh, waist, arm, shoulder, and
neck were massaged for a couple minutes in that order. Then
the child was rolled over to face the floor while the foot, calf,
buttock, back, and scapular were massaged. Afterward, the
back was stretched before changing positions again, this time
lying face up. Once again, the whole entire body was stret-
ched gently for a few minutes before sitting upward. The back
and shoulders were massaged and stretched. Last, the ears
were massaged gently by pulling them up for a few minutes
before pulling them downward.
During the massage session, the parents were encouraged
to be with the patients. To induce a relaxed atmosphere, the
massage room was organized in a certain way and the tem-
perature was carefully moderated. Meanwhile, the massage
was done gently with moderate pressure to avoid pain or
injuries. If the patients cried or showed obvious anxiety, the
massage would be terminated immediately. Talc and oil were
used to facilitate the massage. Importantly, the massage
methodology was standardized for the children to avoid
variations that could affect the results of the study (Fig. 2).
FIG. 2. Thai Traditional Massage in autistic child.

Data collection
Data captured for analysis included the following: (1)
General geographic data including age and sex; (2) General
health data such as chronic diseases, chronic medications,
1358 PIRAVEJ ET AL.

autistic development profile, duration of autism prior to the no statistical differences among both groups. However, the
study, and duration of rehabilitation treatment prior to the massage group had less hyperactivity, hyperactivity index,
study; (3) Behavior assessment data obtained from the Con- and sleep-related problems (Table 1).
ners’ Rating Scales (CRS) on day 0; and (4) SD data on sleep Based on the results obtained from the CTRS, analysis at
behavior assessed by the sleep assessment form. week 8 showed significant improvement in both the control
and the massage groups. The parental report of sleep problems
Statistical analysis revealed that there was significant improvement in the chil-
dren’s sleeping behavior (Tables 2 and 3) When both groups
After the completion of the treatment sessions, patients in
were compared to each other, the results from the CPRS
both the control and massage groups were reassessed by us-
showed that the massage group had higher and completely
ing the CRS and SD. The results were analyzed with standard
different scores for conduct problem and anxiety (Table 4).
statistical methodology by using SPSS version 12 (SPSS Inc.,
However, when the control group was analyzed sepa-
Chicago, IL).
rately, we observed little improvement for learning problem,
Demographic data were analyzed using mean and standard
psychosomatic and hyperactivity whereas none was observed
deviation. For normal distribution, Student’s t-test was used
for conduct problem, impulsivity–hyperactivity, and anxiety.
whereas for abnormal distribution data, the Mann-Whitney U
The small improvement seen for learning problems, psycho-
test was utilized. For quantitative data, percentage and w2 test
somatic complaints, and hyperactivity was not statistically
were used. As for the data from either the control or the in-
significant. In contrast to the control group, when the massage
tervention group, pre- and post-treatment data were analyzed
group was analyzed separately, it showed an improvement in
by using the Wilcoxon signed-rank test. When both groups
all variables except for psychosomatic. Among the variables
were compared to each other, the pre- and post-treatment
with improvement, only anxiety was statistically significant
difference scores were calculated by the Mann-Whitney U
(Tables 2, 3).
test. A p-value <0.05 was considered statistically significant.
Discussion
Results
TTM was commonly and effectively used to improve
The mean age for both the control and intervention groups
health and well-being dating back more than 2500 years.
was around 4 years ( p ¼ 0.48). Both boys and girls were
Hence, in this study, we analyzed the effects of TTM on Thai
equally distributed among both groups. There were 24 boys
autistic children’s behavior using the five subscales of the
in the control group and 25 boys in the massage group. Even
CRS that were translated into Thai and SDs recorded by the
though there were nearly equal numbers of girls participating
parents. Based on several studies utilizing massages,20,25–28
in both groups, there were far fewer girls in the study. Fur-
touch therapies,19 and bioenergetic therapies,29,30 it was
thermore, the mean postdiagnosis of autism was 2.62  1.79
shown that in children with autism and attention-deficit
years for the control group while for the massage group, it
hyperactivity disorder, stereotypical behaviors were dra-
was 2.95  1.79 years. This was not found to be statistically
matically reduced. We hypothesized that TTM would have
different (Table 1). When we compared the baseline analysis
the same or similar effect, even though the technique is
of the CPRS for all six variables, the CTRS for all four variables
slightly different compared to Swedish or regular massages
and the score for sleep behavior obtained from the SD showed
and touch therapy, which utilizes gentle stroking move-
ments. We demonstrated for the first time that TTM can
decrease stereotypical behaviors, self-stimulating behaviors,
Table 1. Demographic Data

Control Massage
Variables group group p-value Table 2. Comparison of the Conners’ Parent
Rating Scales, Conners’ Teacher Rating Scales,
Age (yr) 4.48 (1.80) 4.84 (1.86) 0.48 and Sleep Behavior Before and After Treatment
Sex in Massage Group
Boy 24 25 1.00
Girl 6 5 Variables Week 0 Week 8 p-value
Duration since diagnosis (yr) 2.62 (1.79) 2.95 (1.79) 0.48
Conners’ Parent Rating Scales Conners’ Parent Rating Scales
Conduct problem 0.59 (0.34) 0.69 (0.31) 0.15 Conduct problem 0.69 (0.31) 0.60 (0.26) 0.07
Learning problem 2.02 (0.56) 1.86 (0.55) 0.24 Learning problem 1.86 (0.55) 1.76 (0.48) 0.38
Psychosomatic 0.43 (0.34) 0.41 (0.45) 0.49 Psychosomatic 0.41 (0.45) 0.41 (0.32) 0.53
Impulsivity–hyperactivity 1.65 (0.65) 1.62 (0.60) 0.77 Impulsivity–hyperactivity 1.62 (0.60) 1.44 (0.40) 0.16
Anxiety 0.62 (0.49) 0.76 (0.53) 0.29 Anxiety 0.76 (0.53) 0.62 (0.56) 0.04*
Hyperactivity 1.53 (0.48) 1.45 (0.51) 0.59 Hyperactivity 1.45 (0.51) 1.32 (0.41) 0.10
Conners’ Teacher Rating Scales Conners’ Teacher Rating Scales
Conduct problem 1.11 (0.27) 0.98 (0.38) 0.19 Conduct problem 0.98 (0.38) 0.64 (0.35) 0.00*
Hyperactivity 2.01 (0.34) 1.78 (0.46) 0.05 Hyperactivity 1.78 (0.46) 1.24 (0.50) 0.00*
Inattention–passivity 1.67 (0.27) 1.56 (0.41) 0.33 Inattention–passivity 1.56 (0.41) 1.18 (0.51) 0.00*
Hyperactivity index 1.80 (0.36) 1.59 (0.49) 0.05 Hyperactivity index 1.59 (0.49) 1.10 (0.49) 0.00*
Sleep behavior 13.90 (7.67) 11.50 (9.23) 0.06 Sleep behavior 11.50 (9.23) 5.33 (3.28) 0.00*

Statistical significance was defined as a p-value of <0.05. *Statistical significance was defined as a p-value of <0.05.
EFFECTS OF THAI TRADITIONAL MASSAGE 1359

Table 3. Comparison of the Conners’ Parent Table 4. Comparison of the Mean Difference
Rating Scales, Conners’ Teacher Rating Scales, of Conners’ Parent Rating Scales, Conners’ Teacher
and Sleep Behavior Before and After Treatment Rating Scales, and Sleep Behavior Between Groups
in Control Group
Control Massage
Variables Week 0 Week 8 p-value Variables group group p-value

Conners’ Parent Rating Scales Conners’ Parent Rating Scales


Conduct problem 0.59 (0.34) 0.63 (0.33) 0.27 Conduct problem
Learning problem 2.02 (0.56) 1.87 (0.53) 0.32 Week 0 0.59 (0.34) 0.69 (0.31)
Psychosomatic 0.43 (0.34) 0.39 (0.25) 0.50 Week 8 0.63 (0.33) 0.60 (0.26)
Impulsivity–hyperactivity 1.65 (0.65) 1.69 (0.57) 0.97 Mean difference 0.04 (0.23) 0.09 (0.27) 0.03*
Anxiety 0.62 (0.49) 0.73 (0.50) 0.17 Learning problem
Hyperactivity 1.53 (0.48) 1.42 (0.42) 0.27 Week 0 2.02 (0.56) 1.86 (0.55)
Conners’ Teacher Rating Scales Week 8 1.87 (0.53) 1.76 (0.48)
Conduct problem 1.11 (0.27) 0.71 (0.26) 0.00* Mean difference 0.15 (0.65) 0.10 (0.53) 0.75
Hyperactivity 2.01 (0.34) 1.49 (0.37) 0.00* Psychosomatic
Inattention–passivity 1.67 (0.27) 1.34 (0.36) 0.00* Week 0 0.43 (0.34) 0.41 (0.45)
Hyperactivity index 1.80 (0.36) 1.28 (0.40) 0.00* Week 8 0.39 (0.25) 0.41 (0.32)
Sleep behavior 13.90 (7.67) 8.20 (6.83) 0.00* Mean difference 0.03 (0.27) 0.01 (0.40) 0.23
Impulsivity–hyperactivity
*Statistical significance was defined as a p-value of <0.05.
Week 0 1.65 (0.65) 1.62 (0.60)
Week 8 1.69 (0.57) 1.44 (0.40)
and increase learning processes by reducing conduct prob- Mean difference 0.03 (0.79) 0.17 (0.58) 0.38
lems and anxiety in the massage group when compared to Anxiety
the control group. After the completion of the study, we Week 0 0.62 (0.49) 0.76 (0.53)
offered the control group TTM. Week 8 0.73 (0.50) 0.62 (0.56)
Mean difference 0.11 (0.61) 0.14 (0.32) 0.01*
Data from various studies have all shown the benefits of
Hyperactivity
massages. For instance, two studies showed a reduction in Week 0 1.53 (0.48) 1.45 (0.51)
touch aversion and stereotypic behaviors (e.g., rocking), in- Week 8 1.42 (0.42) 1.32 (0.41)
creased attentiveness in a classroom situation, initiated touch Mean difference 0.11 (0.45) 0.14 (0.41) 0.60
more frequently with their peers during playtime, showed less Conners’ Teacher Rating Scales
fussing and crying, and self-stimulating behaviors.19,20 Even
Conduct problem
though we were able to detect a reduction in stereotypic be- Week 0 1.11 (0.27) 0.98 (0.38)
haviors in our study, we did not see any significant increase in Week 8 0.71 (0.26) 0.64 (0.35)
the attention variable, in off-task and on-task behaviors, in the Mean difference 0.39 (0.22) 0.33 (0.24) 0.21
intervention group. It was possible that this discrepancy was Hyperactivity
due to the different techniques used, frequency, when the Week 0 2.01 (0.34) 1.78 (0.46)
children were massaged, and length of the treatment sessions. Week 8 1.49 (0.37) 1.24 (0.50)
In our study, we did not measure for touch aversion. Mean difference 0.52 (0.34) 0.54 (0.35) 0.80
In another study, patients receiving massages became Inattention–passivity
more lucid in their verbal communication, were more re- Week 0 1.67 (0.27) 1.56 (0.41)
Week 8 1.34 (0.36) 1.18 (0.51)
laxed and calmer, more communicative nonverbally, became
Mean difference 0.32 (0.22) 0.38 (0.22) 0.28
more tolerant of touch, and the bonding between parents Hyperactivity index
and children improved significantly.25 However, the inves- Week 0 1.80 (0.36) 1.59 (0.49)
tigators did note that the children’s reaction to touch therapy Week 8 1.28 (0.40) 1.10 (0.49)
was varied; some children appeared to be more relaxed Mean difference 0.52 (0.29) 0.49 (0.26) 0.74
during therapy while others were more alert, communica- Sleep Behavior
tive, and their sleep patterns improved after therapy. The Week 0 13.90 (7.67) 11.50 (9.23)
authors believed that these differences within the same Week 8 8.20 (6.83) 5.33 (3.28)
group were short-lived despite its 8-week program. They Mean difference 5.70 (8.56) 6.17 (7.14) 0.85
stated that the sessions may not have been long enough for *Statistical significance was defined as a p-value of <0.05.
lasting changes. We concurred that they should have had
more sessions since they only provided a total of eight
training sessions whereas we provided a total of 16 sessions. measured by the Autism Behavior Checklist (ABC) and the
Even with a total of 16 sessions for 8 weeks, we were unable Early Social Communication (ESC) Scales19 in 4 weeks with a
to see whether there were any other significant differences total of eight therapy sessions. We attributed this difference
between the massage and control groups aside from anxiety to the questionnaires used.
and conduct problems. Furthermore, we believed that an Meanwhile, in another study, all the parents reported that
8-week program may not be sufficient enough to detect they felt physically and emotionally closer to their children
improvement in other variables even though Field et al. and subsequently that the relationship with their children
were able to detect fewer autistic behaviors (touch aversion, had been enhanced18 because they were able to display cues
off-task behavior, orienting to sounds, and stereotypic be- for touch. This emotional bonding was consistent with the
haviors),19 and an improvement in social relations that was findings of other massage studies with children with a range
1360 PIRAVEJ ET AL.

of disabilities.31 As for our study, we did not assess emo- a relatively short time even though three studies, conducted
tional bonding and attachment between the parents and their in 1 month,20 8 weeks,18 and 4 weeks,19 were able to show
autistic children because the massage was done by a pro- some changes in the intervention group. Although in our
fessional. Yet we acknowledged that massage did affect the study we were not able to detect many significant behavioral
behaviors of the children to the extent that it could improve changes by 8 weeks, from our findings, TTM may be a useful
their relationship with their parents. It would be interesting treatment option for autistic children.
to see whether TTM was able to improve the children’s social
skills and communication with their peers and other family Recommendations
members.
Similar changes have also been noted for child and ado- We suggested that for future studies, the duration be ex-
lescent psychiatric inpatients diagnosed with adjustment and tended with crossover to avoid parent biases. Importantly, a
depressive disorders. They showed significantly less de- larger sample size may demonstrate more visible significant
pression and anxiety through measurements of salivary and improvements in behavioral changes in the massage group.
urinary cortisol (associated with stress), increase in cooper- Furthermore, a 12-month follow-up interview or question-
ation, reduction in night waking, and an increase in time naire may reveal the longer-term outcomes of TTM. As for
spent sleeping after receiving massage therapies.28 Along the our study, we were unable to follow up our patients upon
same lines, another massage study did not rely only on the completion of the study since most of them were referred
subjective data but more on objective data by focusing on to the Centre, which will be a challenge for future studies.
biological measurements such as electroencephalography Also, other scales should be used in conjunction with the
(EEG) wave changes,32 and vagal activity by measuring CRS to determine whether other variables have improved
heart rate.32 From EEG wave changes, Diego and colleagues over time. Measurements from ABC and ESC will allow us to
were able to show that massage therapies increased alertness expand on other variables that cannot be seen from just using
in autistic patients, especially on math tasks. The other study the CRS. In addition, to avoid any biases in the results re-
using vagal tones showed an increase of this measurement ported by the parents, teachers, or other people involved in
during massage therapy, which was often associated with the study, videotaping the assessment sessions and the pa-
enhanced attentiveness and a more relaxed state.33 One of the tient’s sleeping pattern at home could help investigators in
differences between these studies and ours was that we did interpreting the results.
not access for biological measurements, which could help sub- It was important to emphasize that studies based solely on
stantiate results not found significant obtained from the CRS. the CRS, ABC, and ESC forms were limited by their subjec-
tive nature and possible bias from both the parents and
teachers. Therefore, objective data in the form of biological
Study limitations measurements studies are also needed to confirm the results.
The results from the CRS revealed that both groups were
able to reduce stereotypical behaviors. Since there were no Conclusions
differences reported by the teacher, we hypothesized that the Overall, we showed that this type of massage was able to
CTRS might not be able to provide reliable data as compared significantly reduce conduct problems and anxiety in Thai
to the data from the CPRS. One possible explanation is that autistic children. Therefore, we concluded that TTM could be
the teacher may not be familiar with the patients compared used as a complementary therapy for autistic children.
to the parents and their observations might be limited. Be-
sides, children were well known to behave differently while
Acknowledgments
in school from when they were at home with their parents.
As for the results obtained from the CPRS, it was shown This work was funded by the Asia Research Centre,
that in the control group, there was an improvement in Chulalongkorn University. We would like to thank all the
learning problems, psychosomatic, and hyperactivity vari- participants, parents, and teachers for their involvement in
ables, whereas in the massage group, improvement was seen the study. Source of support: Grant #009=2549.
in five of six variables: conduct problems, learning problems,
impulsivity–hyperactivity, anxiety, and hyperactivity. Inter- Disclosure Statement
estingly, only conduct problems and anxiety were found to
be statistically significant in the massage group. The reason No competing financial interests exist.
for this may be that the study’s sample size may have been
too small to show any significant improvement in the other References
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Address correspondence to:
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20. Escalona A, Field T, Singer-Strunck R et al. Brief report:
Improvements in the behavior of children with autism fol- E-mail: knpiravej@hotmail.com
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