According to the Centers for Disease Control and Prevention, about 1 in 68 U.S. children are diagnosed with an autism spectrum disorder (ASD)1, which includes several conditions that were diagnosed separately until recently, but which are now under one umbrella. Today, those whose symptoms were previously diagnosed as Asperger’s syndrome, pervasive developmental disorder or autistic disorder are now included as part of ASD.
There is no definitive cure for ASD, so many parents are looking for help managing symptoms and behaviors that are common with ASD. However, the wide range of characteristics associated with ASD precludes even a “best treatment.”2
But anecdotal reports and small studies continue to spotlight how massage therapy may benefit people with ASD.3 Nurturing touch and regular sensory integration appear to reduce the social, communication, behavioral, learning, thinking and problem solving-challenges associated with ASD. In particular, craniosacral therapy and deep pressure massage are receiving attention as a possible means to help manage ASD behavioral patterns.
A Quick Look at ASD
Traditional ASD treatments generally involve input from physicians, psychiatrists, psychologists, social workers, occupational therapists, physical therapists, speech and language pathologists, and other experts. Pharmaceuticals are also often used to control symptoms associated with ASD, such as an aversion to touch, gastrointestinal (GI) disorders, anxiety, hyperactivity, sleep disturbance, repetitive behavior, as well as the inability to verbally communicate, make eye contact or interact with others, and additional behaviors that may lead to injury.4
At this point, experts believe that ASD is a developmental disability triggered by complex neurodevelopment disorders5—or abnormalities in brain structure and function. Supporting this theory is the fact that scans show distinct differences in the shape and structure of an autistic child’s brain vs. a neurotypical child’s brain.6 These differences appear to block, distort or disorganize sensory information, a condition called sensory processing disorder (SPD).
Like ASD, there is no known cause for SPD and no cure. Nor can the medical community categorically explain how the two distinct disorders affect one another. What is known, however, is that an estimated 96 percent of ASD patients report some degree of altered sensitivity to sensory stimuli, and a majority of those cases include tactile sensitivities.7
SPD and ASD
SPD exists when the brain cannot detect multiple sensory signals or organize them into one appropriate response. This misfire likely causes the developmental disabilities that affect how an individual on the autistic spectrum learns, thinks and problem-solves.
“There are eight sensory systems in your body that are supposed to take in stimulation around you, integrate that information so your body can respond appropriately and help you feel safe in the world around you,” explains Tami Goldstein, certified craniosacral therapist and autism advocate and educator. Goldstein also authored Coming Through the Fog, a biographical story about her now adult daughter’s lifelong journey through autism. “Maladaptive behaviors you see in children with autism are because their sensory system is either over-registering or under-registering stimulation. So they don’t— they can’t—feel comfortable moving around their world,” Goldstein emphasizes.
Related: Tami's Work With Massage Clients on the Autism Spectrum
Making Sense of It All
Whether beginning the first or 50th massage therapy session with an individual on the autism spectrum, massage therapists need to understand that the combination of SPD and ASD can create reactions that seemingly come out of nowhere and change on a dime, emphasizes Rachel Benbow, Harrisburg, Pennsylvania-based licensed massage therapist and owner of The Roots of Health, where she practices craniosacral therapy and therapeutic massage. “You have to be extremely adaptable,” Benbow says. “SPD can cause those with ASD to quickly become overloaded and then their needs change without warning. Sheet texture, music, a room’s smell or lighting, your touch—all these things may be acceptable one moment but not the next.”
Following are some sensory precautions that are particularly relevant for a massage therapist working with individuals with ASD and SPD:
1. Visual: In some cases, the eyes aren’t working together or there’s a blind spot. “Never approach someone on the autism spectrum full on. It might be too much information too quickly,” Goldstein says. Instead, approach the table from the side.
2. Auditory: Some individuals are unable to filter where a sound is coming from. The primal response is first to experience fear, and then to run. Noise-canceling headphones, a soft voice or gentle classical music may help.
3. Olfactory: When the sense of smell misfires, any aroma, including a massage cream or oil, may elicit high-level anxiety and alarming fear. Letting the individual sniff a cotton ball with a hint of essential oil may help—although Goldstein emphasizes that it can take some experimentation to find a scent that won’t cause overreaction.
4. Gustatory: The sense of taste does not directly affect massage therapy, but since SPD is systemic, one sense misfiring can affect the others, so being aware is essential.
5. Tactile: Individuals with ASD and SPD are often over- or under-sensitive to touch. If over-registering, everything seems to be coming at them too fast and their muscles send a message to flee danger. If under-registered, there’s little to no awareness of tactile stimulation. In either case, massage therapists should move slowly toward the table, giving the individual time to see, hear and feel your approach. When the table sheets are an issue, try a chair massage. And if your very touch is threatening, take a break or quit for the day.
6. Vestibular: This refers to the sense of head movement in space, which plays a role in the body’s sense of balance, awareness of space, gravity and movement. When the vestibular system malfunctions, an individual feels “lost in space.” A weighted lap pad or blanket may help, or use a massage chair rather than a table.
7. Proprioceptive: Linked to the vestibular and tactile systems, the proprioceptive system allows for body awareness, which tells the mind where the body begins and ends, and with how much force and through what line of motion to move. “Children whose proprioceptive system is not working may find touch extremely alarming, since they can’t sense where they’re being touched,” Benbow explains. To help individuals feel more at ease and less “lost,” Benbow places an unbreakable mirror in front of the table so individuals can see which area of the body is being massaged. Weighted lap pads or blankets may also help.
8. Interoception: This system is responsible for detecting internal regulation responses, such as breathing, hunger, heart rate and the need to go to the bathroom. A misfiring interoceptive system makes it difficult to understand emotional reactions. If an individual feels uneasy about a massage, their heart may race, muscles may tense up, breathing may become shallow and their stomach may feel fluttery. When these emotional responses can’t be verbalized, it can be terrifying for the individual on the table, and a total meltdown may follow.
Go with the Flow
Regardless of the technique used to help an ASD patient, the key to success rests on following the patient’s lead. Without this ability, massage may never happen.
For Rochelle Ng, a massage therapist located in Beaverton Oregon, that means extreme patience. “Some of the adults I work with have never had therapeutic touch or they experienced abusive touch. They need a lot of time to process what’s happening—especially if someone is about to touch them.”
In fact, Ng may not perform a massage during the initial visit with a new client with ASD. “First, we get to know each other and I explain what to expect during their massage. No surprises! In the second appointment, I might try a brief massage, maybe 10 minutes on just the hands or feet. My goal is a 30-minute session. Often times, this is all they can tolerate.”
Benbow, who uses both craniosacral and massage therapy, agrees, adding that “getting to know you” sessions are the norm with young ones. “Children often need several sessions to build a rapport with their massage therapist. ASD children live in a world of constant discomfort, stress and alarm. Providing a safe space and safe relationship is a critical part of the therapy. We’ll begin CST or massage when it feels right.”
Kristy Detore, licensed massage therapist and certified craniosacral therapist at Oakstone Academy/CCDE Therapies, a school for children with ASD located in Westerville, Ohio, highly recommends a “secret code.” “When a child is nonverbal or can’t make eye contact, I find a way for them to express a need to stop the massage—in case being touched becomes unbearable. Maybe it’s a hand gesture or a leg kick. What’s important is that the child knows I’m watching their every cue, which helps them feel safe.”
Another tip to gain an ASD child’s trust is to first massage mom or dad, explains Doria Walsh, a massage therapist certified in Pediatric Touch Therapy for Autism Spectrum Disorders and the owner at Spectrum Massage, in Harrisburg, Pennsylvania. “Children averse to touch often feel less stressed when they see that massage makes the parent feel good. I’ll even let the child massage a parent, so the child learns the process from both sides of the table.”
Deep Pressure Massage
Deep pressure massage for ASD relies on the massage therapist’s flat palm and fingers, rather than fingertips, and firm, long, strong strokes. To help with proprioceptive issues, it’s recommended that the massage therapist or caregiver explain in a soft, calming voice precisely which body part is being massaged.
No large-scale studies have yet been conducted on massage therapy specific to individuals with ASD. However, small studies and anecdotal research suggests that deep pressure massage may benefit several common physical and cognitive symptoms associated with ASD. In addition, massage therapy has been shown to boost the effects of conventional therapies when theyare used together.8
For example, a 16-week study concludes that massage therapy may decrease the stereotypic touch aversion associated with autistic children. As part of the study, parents performed massage therapy on their ASD child every evening. When the study concluded, parents reported feeling physically and emotionally closer to their child. Perhaps most surprising, the study cites, “Children expressed a range of cues to initiate massage at home.”9
In another study, Improvements in the Behavior of Children with Autism Following Massage Therapy10, 20 children with autism, ages 3 to 6 years, and their parents were randomly assigned to one of two groups. Parents assigned to the massage therapy group were trained by a massage therapist to massage their children for 15 minutes every night before bed. Parents in the control group read books to their children before bed.
After one month, an assessment suggested that children in the massage group exhibited more on-task and social relatedness behavior during play observations at school and fewer sleep problems at home.
One theory behind these positive outcomes, as suggested by a study conducted at the University of California, Los Angeles, is that massage may increase the body’s release of oxytocin (OT), a hormone believed to be an important neurotransmitter within the brain. A 2014 article published in Frontiers in Psychology supports oxytocin’s potential importance, adding that when released in response to activation of various types of sensory nerves, oxytocin appears to increase an individual’s sense of wellbeing, reduce stress and improve levels of social interaction.11
This theory has not been definitively confirmed, and in fact remains a hotly debated topic—particularly after a 2014 study reported that children with autism are no more likely than other children to have low levels of oxytocin in the blood.12 However, the study also concludes that OT levels for those with ASD may be different in the cerebrospinal fluid around the brain. This possibility has been voiced but not yet investigated. Therefore, the hypothesis that an oxytocin-deficiency keys into ASD requires additional research.
Regardless of physiological reasons that might explain why massage therapy may benefit individuals with ASD, Walsh suspects that tactile sensory stimulation is something that this population needs. “We may see children on the autism spectrum engaging in behaviors such as throwing themselves on the floor, banging their head against a wall or hitting themselves. Often they may be seeking sensory input to regulate themselves,” Walsh explains. “If I can get these children to relax into massage therapy, I’m giving them what their central nervous system needs.”
As for the anxiety associated with ASD—which may prevent the relaxation level needed for sleep, increased energy and focus—Detore feels that physically tense muscles may be part of the root problem. “Some individuals with ASD hold their arms tight against their torso or ears, their posture is painfully hunched over or they’re toe-walkers. I find that myofascial release is effective in relaxing that tension and helps calm them down so they can focus better.”
In layman’s terms, those who advocate craniosacral therapy (CST) believe that a loss of flexibility and inflammation in the membrane layers surrounding the brain may play a role in the development and intensity of ASD. CST’s gentle, hands-on technique is designed to enhance the functioning of the membranes, tissues, fluids and bones surrounding or associated with the brain and spinal cord.
To date there is no valid scientific evidence that supports CST’s therapeutic effect—regardless of diagnosis.13 There is, however, one recent study drawing attention. Completed in 2016, The use of CranioSacral therapy for Autism Spectrum Disorders: Benefits from the viewpoints of parents, clients, and therapists14 concludes that CST is “already being professionally recommended as a treatment.” In addition, the study authors deemed positive observations from parents, clients and therapists as proof positive that, “There is worthy cause to further investigate how CST benefits autism spectrum disorders.”
Unlike deep pressure massage therapy, where a muscle may feel more relaxed almost immediately after therapy, the “feeling” that CST produces is less exact. The reaction, however, has been noted time and time again.
For example, Gayle Blyth, RN, spent 14 years using her mother’s instinct and medical knowledge to help her son. “He’s on the spectrum, and we tried everything. Still, though, he didn’t like being touched. I couldn’t hug him, and he was always anxious,” Blyth says.
Then they started working with Goldstein and saw some positive changes.
“I’ve literally watched his body relax when he’s on Tami’s table,” Blyth says. “And when he leaves the office, he’ll come up to me, put my arms around him and ask for a tight hug. This is something he needs … me, too! It’s an amazing thing.”
A Touch of Reality
The relationship between massage therapy and autism spectrum disorder, with or without sensory processing disorder, remains unconfirmed. Despite limited scientific data, researchers and medical professionals are still seriously considering the role massage therapy can play in helping individuals with ASD, and some have begun planning for larger controlled studies.
Until more solid research corroborates how and why touch therapy benefits individuals with ASD, however, anecdotal evidence continues to reinforce the promise of massage therapy when combined with other interventions.
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