Effects of Thai Traditional Massage on Autistic Children's Behavior

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
Abstract
<strong>Effects</strong> <strong>of</strong> <strong>Thai</strong> <strong>Traditional</strong> <strong>Massage</strong> 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
Objectives: The objective <strong>of</strong> this study was to access whether there were any therapeutic effects <strong>of</strong> <strong>Thai</strong> <strong>Traditional</strong>
<strong>Massage</strong> (TTM) on major behavioral and emotional disturbances in <strong>Thai</strong> autistic children.
Design: This was a randomized controlled trial study.
Settings=location: The study was conducted at the Rehabilitation Centre <strong>of</strong> the <strong>Thai</strong> Red Cross Society.
Subjects: A total <strong>of</strong> 60 autistic children between the ages <strong>of</strong> 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 improvement
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 <strong>of</strong> 8 weeks, our findings suggested that TTM could be used as a complementary
therapy for autistic children in <strong>Thai</strong>land.
Introduction
In recent years, autism spectrum disorders have received
increased attention in youngsters. The number <strong>of</strong> individuals
diagnosed with autism has dramatically increased in the
past few years. Similarly, in <strong>Thai</strong>land, autism has also become
a more commonly diagnosed childhood brain disorder. It was
found that 4.4 <strong>of</strong> 1000 <strong>Thai</strong> children were prone to be autistic,
and the prevalence rate has been 9.9 children per 10,000
populations. 1 These patients typically demonstrated problems
in behavior and were less effective communicators.
Interestingly, no single cause has been identified for the
development <strong>of</strong> autism. 2–7 Presently, since neuropsychological
etiology is essentially unknown, 8,9 it is difficult to treat
autism from a pharmaceutical standpoint. 2,3,10 This situation
has created a demand for nonpharmaceutically based treatments
and has led to the development <strong>of</strong> treatment methodologies
in a wide variety <strong>of</strong> fields.
For example, sensory integration therapy (SI) uses the
child’s intrinsic motivation to help change the child’s adaptive
response by utilizing a wide variety <strong>of</strong> play media, activities,
and=or equipment to stimulate sensory integration. 11 This
process occurs at the neuronal cellular level where many parts
<strong>of</strong> the nervous system work together to allow the person to
interact with the environment effectively and experience appropriate
satisfaction. 12 At each session, the therapist will
select a sensory agent that has either a facilitatory or an inhibitory
effect on the child’s nervous system that will target
certain adaptive responses such as reflex integration, adequate
postural adjustments, movement successes, increased alertness
and awareness <strong>of</strong> input, self-regulation without maladaptive
emotional reactions, and abilities to start and
participate in the task through to completion. 13 This technique
has been shown to help decrease tactile and other sensitivities
to stimuli known to interfere with the children’s ability to
play, learn, and interact. 14,15
Departments <strong>of</strong> 1 Rehabilitation Medicine and 3 Psychiatry, Faculty <strong>of</strong> Medicine, Chulalongkorn University, Bangkok, <strong>Thai</strong>land.
2 WATPO <strong>Thai</strong> <strong>Traditional</strong> Medicine and <strong>Massage</strong> School, Bangkok, <strong>Thai</strong>land.
4 Rehabilitation Centre, <strong>Thai</strong> Red Cross Society, Samuthprakarn, <strong>Thai</strong>land.
1355

1356 PIRAVEJ ET AL.
Other new approaches have emerged to improve socialization
and learning abilities <strong>of</strong> these patients. 2,9,16,17 These
interventions are starting to involve the parents <strong>of</strong> the patients
in the therapeutic sessions. In addition, some <strong>of</strong> the skills used
by the occupational therapists are being transferred to the
parents such as massages or touch therapies so they can continue
administering these techniques at home at their own
convenience. 18
It has been reported that tactile stimulation in the form <strong>of</strong>
massage could reduce stereotypical behavior and touch aversions
as well as improve sleep disturbance, classroom concentration,
and social interactions. 19 Another study showed
massages delivered by the parents significantly improved
sleep and enhanced behavior control in preschool autistic
children. 20 Likewise, Cullen-Powell et al. (2005) demonstrated
that massage therapy was able to calm and relax autistic
children enough to pay attention to classroom activities. 18
Though these initial evidences are encouraging, the number <strong>of</strong>
studies is still scarce and warrant further studies in this area.
Of note, <strong>Thai</strong> <strong>Traditional</strong> <strong>Massage</strong> (TTM) has never been
studied in autistic patients even though <strong>Thai</strong> massages have
been used frequently as an alternative therapy dating back
more than 2500 years ago. This technique has been traditionally
attributed to Shivaga Komarapaj, the Lord <strong>of</strong> Buddha’s
doctor and the Father <strong>of</strong> <strong>Thai</strong> Medicine. The <strong>Thai</strong>s have
combined Indian yoga with Chinese acupressure, resulting in
a unique <strong>Thai</strong> style massage. It is noteworthy that TTM does
not concentrate on the muscles but focuses on the entire
physical body by manipulating invisible channels and energy
bodies known as auric body. By applying pressure to vital
points along these channels, the therapist’s internal energy is
used to boost and stimulate the flow <strong>of</strong> the patient’s internal
energy, and direct it toward the patient’s ailing organs and
glands. Hence, TTM is considered to be both spiritual and
therapeutic. For this reason, we wanted to investigate whether
this alternative therapy, TTM, can be used to improve
behavioral and emotional disturbances in <strong>Thai</strong> autistic children
in combination with SI.
Materials and Methods
Participant selection
The study protocol was approved by The Institutional
Review Board <strong>of</strong> the Faculty <strong>of</strong> Medicine, Chulalongkorn
University, Bangkok, <strong>Thai</strong>land. This was a randomized,
controlled clinical trial comparing the effects <strong>of</strong> TTM, a behavioral
intervention, with SI in <strong>Thai</strong> autistic children between
the ages <strong>of</strong> 3 and 10 who were recruited from the Rehabilitation
Centre <strong>of</strong> the <strong>Thai</strong> Red Cross Society. This Centre
received referrals from several doctors from different hospitals
located throughout <strong>Thai</strong>land and hence was the perfect
venue for us to recruit our participants.
A total <strong>of</strong> 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 massage
group. The preferred and ideal treatment for the massage
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 accompanied
with SI. Each participant was required to have a
definite diagnosis <strong>of</strong> autistic disorder made by a psychiatrist
based on the Diagnostic and Statistical Manual <strong>of</strong> Mental
Disorders (DSM IV) criteria. In <strong>Thai</strong>land, diagnosing children
with autism based on the criteria <strong>of</strong> DSM IV is acceptable. 21
Parental or guardian consent was obtained from each participant
prior to starting the study. The exclusion criteria
included contraindications for TTM such as hematological
disorders, fractures, arthritis, joint dislocation, fevers, cardiovascular,
and pulmonary diseases. Additional exclusionary
criteria included the inability to complete 80% <strong>of</strong> the
treatment program or receive a total <strong>of</strong> 13 massage sessions.
Patients with noncooperative parents or guardians were excluded
to avoid patients lost to follow-up or withdrawals. As
per Good Clinical Trial practices, all patients were informed
that they could withdraw from the study at any time without
losing any current health care benefits from the Centre.
Randomization and assessment tools
The participants were randomized into the control and
massage group via block randomization. This technique
randomly allocates permutations <strong>of</strong> treatments within each
block, maintaining the same size for each group.
The parents were not blinded in accordance with local IRB
guidelines, but the teacher (occupational therapist) was blinded.
After the patients were randomized, the parents and
teacher were required to fill out the Conners’ Parent Rating
Scales (CPRS) 22 and Conners’ Teacher Rating Scales (CTRS) 22
on day 0 and at the end <strong>of</strong> week 8, respectively. Aside from
that, the parents were also required to record their autistic
children’s sleeping behaviors every week in the Sleep Diary
(SD). 23 Assessment using the SD has been shown to be effective
in identifying improvement in sleep disorders in autistic
children. 24 At week 8, both groups were re-evaluated
using the same questionnaires from day 0 (Fig. 1).
Clinical interventions
Both the control and massage groups received SI by the
same occupational therapist, 2 sessions per week, 1 hour per
session, for a duration <strong>of</strong> 8 weeks, for a total <strong>of</strong> 16 sessions.
For each child, the therapist created an appropriate and individualized
therapeutic environment. The sessions utilized
FIG. 1. A randomized controlled trial Consolidated Standards
<strong>of</strong> Reporting Trials (CONSORT) flow diagram.

EFFECTS OF THAI TRADITIONAL MASSAGE 1357
the following key principles <strong>of</strong> SI: (1) Just Right Challenge,
(2) The Adaptive Response, (3) Active Engagement, and (4)
Child Directed. 15 For the ‘‘Just Right Challenge,’’ the therapist
created playful activities that were slightly challenging
but easily accomplished by the child. This approach balanced
the abilities <strong>of</strong> 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 activities
were given.
Next, for the ‘‘Active Engagement,’’ the therapist continued
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 <strong>of</strong> activities that targeted
specific sensory deficits. These activities incorporated vestibular
integration, proprioceptive and tactile stimulation. A
planned activity schedule was inserted into the child’s natural
environment. Last, for the ‘‘Child Directed,’’ the therapist
followed the child’s lead or suggestions in creating more
sensory-rich activities to develop a higher cognitive level and
motor functions. All <strong>of</strong> these activities also included the
child’s caregivers and other relevant pr<strong>of</strong>essionals.
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 intervention
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 significantly
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 <strong>of</strong> 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 <strong>of</strong> 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 stretched
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 temperature
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 <strong>of</strong> the study (Fig. 2).
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,
FIG. 2. <strong>Thai</strong> <strong>Traditional</strong> <strong>Massage</strong> in autistic child.

1358 PIRAVEJ ET AL.
autistic development pr<strong>of</strong>ile, duration <strong>of</strong> autism prior to the
study, and duration <strong>of</strong> rehabilitation treatment prior to the
study; (3) Behavior assessment data obtained from the Conners’
Rating Scales (CRS) on day 0; and (4) SD data on sleep
behavior assessed by the sleep assessment form.
Statistical analysis
After the completion <strong>of</strong> the treatment sessions, patients in
both the control and massage groups were reassessed by using
the CRS and SD. The results were analyzed with standard
statistical methodology by using SPSS version 12 (SPSS Inc.,
Chicago, IL).
Demographic data were analyzed using mean and standard
deviation. For normal distribution, Student’s t-test was used
whereas for abnormal distribution data, the Mann-Whitney U
test was utilized. For quantitative data, percentage and w 2 test
were used. As for the data from either the control or the intervention
group, pre- and post-treatment data were analyzed
by using the Wilcoxon signed-rank test. When both groups
were compared to each other, the pre- and post-treatment
difference scores were calculated by the Mann-Whitney U
test. A p-value

EFFECTS OF THAI TRADITIONAL MASSAGE 1359
Table 3. Comparison <strong>of</strong> the Conners’ Parent
Rating Scales, Conners’ Teacher Rating Scales,
and Sleep Behavior Before and After Treatment
in Control Group
Variables Week 0 Week 8 p-value
Conners’ Parent Rating Scales
Conduct problem 0.59 (0.34) 0.63 (0.33) 0.27
Learning problem 2.02 (0.56) 1.87 (0.53) 0.32
Psychosomatic 0.43 (0.34) 0.39 (0.25) 0.50
Impulsivity–hyperactivity 1.65 (0.65) 1.69 (0.57) 0.97
Anxiety 0.62 (0.49) 0.73 (0.50) 0.17
Hyperactivity 1.53 (0.48) 1.42 (0.42) 0.27
Conners’ Teacher Rating Scales
Conduct problem 1.11 (0.27) 0.71 (0.26) 0.00*
Hyperactivity 2.01 (0.34) 1.49 (0.37) 0.00*
Inattention–passivity 1.67 (0.27) 1.34 (0.36) 0.00*
Hyperactivity index 1.80 (0.36) 1.28 (0.40) 0.00*
Sleep behavior 13.90 (7.67) 8.20 (6.83) 0.00*
*Statistical significance was defined as a p-value <strong>of</strong>

1360 PIRAVEJ ET AL.
<strong>of</strong> disabilities. 31 As for our study, we did not assess emotional
bonding and attachment between the parents and their
autistic children because the massage was done by a pr<strong>of</strong>essional.
Yet we acknowledged that massage did affect the
behaviors <strong>of</strong> the children to the extent that it could improve
their relationship with their parents. It would be interesting
to see whether TTM was able to improve the children’s social
skills and communication with their peers and other family
members.
Similar changes have also been noted for child and adolescent
psychiatric inpatients diagnosed with adjustment and
depressive disorders. They showed significantly less depression
and anxiety through measurements <strong>of</strong> salivary and
urinary cortisol (associated with stress), increase in cooperation,
reduction in night waking, and an increase in time
spent sleeping after receiving massage therapies. 28 Along the
same lines, another massage study did not rely only on
subjective data but more on objective data by focusing on
biological measurements such as electroencephalography
(EEG) wave changes, 32 and vagal activity by measuring
heart rate. 32 From EEG wave changes, Diego and colleagues
were able to show that massage therapies increased alertness
in autistic patients, especially on math tasks. The other study
using vagal tones showed an increase <strong>of</strong> this measurement
during massage therapy, which was <strong>of</strong>ten associated with
enhanced attentiveness and a more relaxed state. 33 One <strong>of</strong> the
differences between these studies and ours was that we did
not access for biological measurements, which could help substantiate
results not found significant obtained from the CRS.
Study limitations
The results from the CRS revealed that both groups were
able to reduce stereotypical behaviors. Since there were no
differences reported by the teacher, we hypothesized that the
CTRS might not be able to provide reliable data as compared
to the data from the CPRS. One possible explanation is that
the teacher may not be familiar with the patients compared
to the parents and their observations might be limited. Besides,
children were well known to behave differently while
in school from when they were at home with their parents.
As for the results obtained from the CPRS, it was shown
that in the control group, there was an improvement in
learning problems, psychosomatic, and hyperactivity variables,
whereas in the massage group, improvement was seen
in five <strong>of</strong> six variables: conduct problems, learning problems,
impulsivity–hyperactivity, anxiety, and hyperactivity. Interestingly,
only conduct problems and anxiety were found to
be statistically significant in the massage group. The reason
for this may be that the study’s sample size may have been
too small to show any significant improvement in the other
variables and=or the CPRS may not be as reliable in obtaining
accurate information from the parents since they
were not blinded.
Also, we would like to point out that even though the CRS
used in this study was not the most sensitive and reliable
measurement in autistic patients, we continued to use the
CRS based on another study. 20 The questionnaire was
translated into <strong>Thai</strong> and has been widely used in <strong>Thai</strong>land to
assess behavioral problems in children.
Another limitation may be the duration <strong>of</strong> the study, because
it was difficult to assess any real behavioral changes in
a relatively short time even though three studies, conducted
in 1 month, 20 8 weeks, 18 and 4 weeks, 19 were able to show
some changes in the intervention group. Although in our
study we were not able to detect many significant behavioral
changes by 8 weeks, from our findings, TTM may be a useful
treatment option for autistic children.
Recommendations
We suggested that for future studies, the duration be extended
with crossover to avoid parent biases. Importantly, a
larger sample size may demonstrate more visible significant
improvements in behavioral changes in the massage group.
Furthermore, a 12-month follow-up interview or questionnaire
may reveal the longer-term outcomes <strong>of</strong> TTM. As for
our study, we were unable to follow up our patients upon
the completion <strong>of</strong> the study since most <strong>of</strong> them were referred
to the Centre, which will be a challenge for future studies.
Also, other scales should be used in conjunction with the
CRS to determine whether other variables have improved
over time. Measurements from ABC and ESC will allow us to
expand on other variables that cannot be seen from just using
the CRS. In addition, to avoid any biases in the results reported
by the parents, teachers, or other people involved in
the study, videotaping the assessment sessions and the patient’s
sleeping pattern at home could help investigators in
interpreting the results.
It was important to emphasize that studies based solely on
the CRS, ABC, and ESC forms were limited by their subjective
nature and possible bias from both the parents and
teachers. Therefore, objective data in the form <strong>of</strong> biological
measurements studies are also needed to confirm the results.
Conclusions
Overall, we showed that this type <strong>of</strong> massage was able to
significantly reduce conduct problems and anxiety in <strong>Thai</strong>
autistic children. Therefore, we concluded that TTM could be
used as a complementary therapy for autistic children.
Acknowledgments
This work was funded by the Asia Research Centre,
Chulalongkorn University. We would like to thank all the
participants, parents, and teachers for their involvement in
the study. Source <strong>of</strong> support: Grant #009=2549.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Krisna Piravej, M.D.
Department <strong>of</strong> Rehabilitation Medicine
Faculty <strong>of</strong> Medicine
Chulalongkorn University
Bangkok 10330
<strong>Thai</strong>land
E-mail: knpiravej@hotmail.com

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