Effects of Thai Traditional Massage on AutisticChildren’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 TraditionalMassage (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 Scalesat 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 inthe 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, hyperactivityindex, and sleeping behavior. However, results from the Conners’ Parent Questionnaire revealed an improve-ment only for anxiety ( p¼ 0.04) in the massage group, whereas when both groups were compared, a significantimprovement in conduct problem ( p¼ 0.03) and anxiety ( p¼ 0.01) was found. Results indicated that TTM mayhave 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 complementarytherapy for autistic children in Thailand.

Introduction

In recent years, autism spectrum disorders have receivedincreased attention in youngsters. The number of individ-

uals diagnosed with autism has dramatically increased in thepast few years. Similarly, in Thailand, autism has also becomea more commonly diagnosed childhood brain disorder. It wasfound that 4.4 of 1000 Thai children were prone to be autistic,and the prevalence rate has been 9.9 children per 10,000populations.1 These patients typically demonstrated prob-lems in behavior and were less effective communicators.

Interestingly, no single cause has been identified for thedevelopment of autism.2–7 Presently, since neuropsychologi-cal etiology is essentially unknown,8,9 it is difficult to treatautism from a pharmaceutical standpoint.2,3,10 This situationhas created a demand for nonpharmaceutically based treat-ments and has led to the development of treatment method-ologies in a wide variety of fields.

For example, sensory integration therapy (SI) uses thechild’s intrinsic motivation to help change the child’s adaptiveresponse by utilizing a wide variety of play media, activities,and=or equipment to stimulate sensory integration.11 Thisprocess occurs at the neuronal cellular level where many partsof the nervous system work together to allow the person tointeract with the environment effectively and experience ap-propriate satisfaction.12 At each session, the therapist willselect a sensory agent that has either a facilitatory or an inhib-itory effect on the child’s nervous system that will targetcertain adaptive responses such as reflex integration, adequatepostural adjustments, movement successes, increased alert-ness and awareness of input, self-regulation without mala-daptive emotional reactions, and abilities to start andparticipate in the task through to completion.13 This techniquehas been shown to help decrease tactile and other sensitivitiesto stimuli known to interfere with the children’s ability toplay, learn, and interact.14,15

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

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

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Other new approaches have emerged to improve sociali-zation and learning abilities of these patients.2,9,16,17 Theseinterventions are starting to involve the parents of the patientsin the therapeutic sessions. In addition, some of the skills usedby the occupational therapists are being transferred to theparents such as massages or touch therapies so they can con-tinue administering these techniques at home at their ownconvenience.18

It has been reported that tactile stimulation in the form ofmassage could reduce stereotypical behavior and touch aver-sions as well as improve sleep disturbance, classroom con-centration, and social interactions.19 Another study showedmassages delivered by the parents significantly improvedsleep and enhanced behavior control in preschool autisticchildren.20 Likewise, Cullen-Powell et al. (2005) demonstratedthat massage therapy was able to calm and relax autisticchildren enough to pay attention to classroom activities.18

Though these initial evidences are encouraging, the number ofstudies is still scarce and warrant further studies in this area.

Of note, Thai Traditional Massage (TTM) has never beenstudied in autistic patients even though Thai massages havebeen used frequently as an alternative therapy dating backmore than 2500 years ago. This technique has been tradition-ally attributed to Shivaga Komarapaj, the Lord of Buddha’sdoctor and the Father of Thai Medicine. The Thais havecombined Indian yoga with Chinese acupressure, resulting ina unique Thai style massage. It is noteworthy that TTM doesnot concentrate on the muscles but focuses on the entirephysical body by manipulating invisible channels and energybodies known as auric body. By applying pressure to vitalpoints along these channels, the therapist’s internal energy isused to boost and stimulate the flow of the patient’s internalenergy, and direct it toward the patient’s ailing organs andglands. Hence, TTM is considered to be both spiritual andtherapeutic. For this reason, we wanted to investigate whe-ther this alternative therapy, TTM, can be used to improvebehavioral and emotional disturbances in Thai autistic chil-dren in combination with SI.

Materials and Methods

Participant selection

The study protocol was approved by The InstitutionalReview Board of the Faculty of Medicine, ChulalongkornUniversity, Bangkok, Thailand. This was a randomized,controlled clinical trial comparing the effects of TTM, a behav-ioral intervention, with SI in Thai autistic children betweenthe ages of 3 and 10 who were recruited from the Re-habilitation Centre of the Thai Red Cross Society. This Centrereceived referrals from several doctors from different hospi-tals located throughout Thailand and hence was the perfectvenue for us to recruit our participants.

A total of 60 autistic children were enrolled in the study andwere randomized into two groups: massage group (n¼ 30)and control group (n¼ 30). The control group received onlySI, 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 hasnever been studied in autistic children, the local InstitutionalReview Board (IRB) prohibited its use unless it was accom-panied with SI. Each participant was required to have adefinite diagnosis of autistic disorder made by a psychiatrist

based on the Diagnostic and Statistical Manual of MentalDisorders (DSM IV) criteria. In Thailand, diagnosing childrenwith autism based on the criteria of DSM IV is acceptable.21

Parental or guardian consent was obtained from each par-ticipant prior to starting the study. The exclusion criteriaincluded contraindications for TTM such as hematologicaldisorders, fractures, arthritis, joint dislocation, fevers, car-diovascular, and pulmonary diseases. Additional exclusion-ary criteria included the inability to complete 80% of thetreatment program or receive a total of 13 massage sessions.Patients with noncooperative parents or guardians were ex-cluded to avoid patients lost to follow-up or withdrawals. Asper Good Clinical Trial practices, all patients were informedthat they could withdraw from the study at any time withoutlosing any current health care benefits from the Centre.

Randomization and assessment tools

The participants were randomized into the control andmassage group via block randomization. This techniquerandomly allocates permutations of treatments within eachblock, maintaining the same size for each group.

The parents were not blinded in accordance with local IRBguidelines, but the teacher (occupational therapist) was blin-ded. After the patients were randomized, the parents andteacher were required to fill out the Conners’ Parent RatingScales (CPRS)22 and Conners’ Teacher Rating Scales (CTRS)22

on day 0 and at the end of week 8, respectively. Aside fromthat, the parents were also required to record their autisticchildren’s sleeping behaviors every week in the Sleep Diary(SD).23 Assessment using the SD has been shown to be ef-fective in identifying improvement in sleep disorders in au-tistic children.24 At week 8, both groups were re-evaluatedusing the same questionnaires from day 0 (Fig. 1).

Clinical interventions

Both the control and massage groups received SI by thesame occupational therapist, 2 sessions per week, 1 hour persession, for a duration of 8 weeks, for a total of 16 sessions.For each child, the therapist created an appropriate and in-dividualized therapeutic environment. The sessions utilized

FIG. 1. A randomized controlled trial Consolidated Stan-dards of Reporting Trials (CONSORT) flow diagram.

1356 PIRAVEJ ET AL.

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 challengingbut easily accomplished by the child. This approach balancedthe abilities of the child with the challenges given. As for‘‘The Adaptive Response,’’ the therapist observed the child’sability 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 andadvanced abilities. This enabled the child to ‘‘learn how tolearn’’ by incorporating a variety of activities that targetedspecific sensory deficits. These activities incorporated ves-tibular integration, proprioceptive and tactile stimulation. Aplanned 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 moresensory-rich activities to develop a higher cognitive level andmotor functions. All of these activities also included thechild’s caregivers and other relevant professionals.

The second intervention used was TTM. Only the massagegroup received TTM treatments in addition to SI. To avoidvariations in the massage technique, only one masseuse wasemployed to deliver the massages to all patients in the inter-vention group. First, pre-massage rapport was done prior tothe session to reduce the patient’s anxiety or fear. Buildingrapport with the patient prior to the massage treatment sig-nificantly enhanced the patient’s cooperation and willingnessto be massaged. After that, the child was instructed to liedown, facing upward while the massage was administered.The masseuse applied some pressure to the sole of the foot fora few minutes before moving to the foot, leg, thigh, hand, arm,and fingers. Next, the child changed positions by lying on oneside of the body. The foot, leg, thigh, waist, arm, shoulder, andneck were massaged for a couple minutes in that order. Thenthe child was rolled over to face the floor while the foot, calf,buttock, back, and scapular were massaged. Afterward, theback was stretched before changing positions again, this timelying face up. Once again, the whole entire body was stret-ched gently for a few minutes before sitting upward. The backand shoulders were massaged and stretched. Last, the earswere massaged gently by pulling them up for a few minutesbefore pulling them downward.

During the massage session, the parents were encouragedto be with the patients. To induce a relaxed atmosphere, themassage room was organized in a certain way and the tem-perature was carefully moderated. Meanwhile, the massagewas done gently with moderate pressure to avoid pain orinjuries. If the patients cried or showed obvious anxiety, themassage would be terminated immediately. Talc and oil wereused to facilitate the massage. Importantly, the massagemethodology was standardized for the children to avoidvariations that could affect the results of the study (Fig. 2).

Data collection

Data captured for analysis included the following: (1)General geographic data including age and sex; (2) Generalhealth data such as chronic diseases, chronic medications,

FIG. 2. Thai Traditional Massage in autistic child.

EFFECTS OF THAI TRADITIONAL MASSAGE 1357

autistic development profile, duration of autism prior to thestudy, and duration of rehabilitation treatment prior to thestudy; (3) Behavior assessment data obtained from the Con-ners’ Rating Scales (CRS) on day 0; and (4) SD data on sleepbehavior assessed by the sleep assessment form.

Statistical analysis

After the completion of the treatment sessions, patients inboth the control and massage groups were reassessed by us-ing the CRS and SD. The results were analyzed with standardstatistical methodology by using SPSS version 12 (SPSS Inc.,Chicago, IL).

Demographic data were analyzed using mean and standarddeviation. For normal distribution, Student’s t-test was usedwhereas for abnormal distribution data, the Mann-Whitney Utest was utilized. For quantitative data, percentage and w2 testwere used. As for the data from either the control or the in-tervention group, pre- and post-treatment data were analyzedby using the Wilcoxon signed-rank test. When both groupswere compared to each other, the pre- and post-treatmentdifference scores were calculated by the Mann-Whitney Utest. A p-value <0.05 was considered statistically significant.

Results

The mean age for both the control and intervention groupswas around 4 years ( p¼ 0.48). Both boys and girls wereequally distributed among both groups. There were 24 boysin the control group and 25 boys in the massage group. Eventhough there were nearly equal numbers of girls participatingin both groups, there were far fewer girls in the study. Fur-thermore, the mean postdiagnosis of autism was 2.62� 1.79years for the control group while for the massage group, itwas 2.95� 1.79 years. This was not found to be statisticallydifferent (Table 1). When we compared the baseline analysisof the CPRS for all six variables, the CTRS for all four variablesand the score for sleep behavior obtained from the SD showed

no statistical differences among both groups. However, themassage group had less hyperactivity, hyperactivity index,and sleep-related problems (Table 1).

Based on the results obtained from the CTRS, analysis atweek 8 showed significant improvement in both the controland the massage groups. The parental report of sleep problemsrevealed that there was significant improvement in the chil-dren’s sleeping behavior (Tables 2 and 3) When both groupswere compared to each other, the results from the CPRSshowed that the massage group had higher and completelydifferent scores for conduct problem and anxiety (Table 4).

However, when the control group was analyzed sepa-rately, we observed little improvement for learning problem,psychosomatic and hyperactivity whereas none was observedfor conduct problem, impulsivity–hyperactivity, and anxiety.The small improvement seen for learning problems, psycho-somatic complaints, and hyperactivity was not statisticallysignificant. In contrast to the control group, when the massagegroup was analyzed separately, it showed an improvement inall variables except for psychosomatic. Among the variableswith improvement, only anxiety was statistically significant(Tables 2, 3).

Discussion

TTM was commonly and effectively used to improvehealth and well-being dating back more than 2500 years.Hence, in this study, we analyzed the effects of TTM on Thaiautistic children’s behavior using the five subscales of theCRS that were translated into Thai and SDs recorded by theparents. Based on several studies utilizing massages,20,25–28

touch therapies,19 and bioenergetic therapies,29,30 it wasshown that in children with autism and attention-deficithyperactivity disorder, stereotypical behaviors were dra-matically reduced. We hypothesized that TTM would havethe same or similar effect, even though the technique isslightly different compared to Swedish or regular massagesand touch therapy, which utilizes gentle stroking move-ments. We demonstrated for the first time that TTM candecrease stereotypical behaviors, self-stimulating behaviors,

Table 1. Demographic Data

VariablesControlgroup

Massagegroup p-value

Age (yr) 4.48 (1.80) 4.84 (1.86) 0.48Sex

Boy 24 25 1.00Girl 6 5

Duration since diagnosis (yr) 2.62 (1.79) 2.95 (1.79) 0.48Conners’ Parent Rating Scales

Conduct problem 0.59 (0.34) 0.69 (0.31) 0.15Learning problem 2.02 (0.56) 1.86 (0.55) 0.24Psychosomatic 0.43 (0.34) 0.41 (0.45) 0.49Impulsivity–hyperactivity 1.65 (0.65) 1.62 (0.60) 0.77Anxiety 0.62 (0.49) 0.76 (0.53) 0.29Hyperactivity 1.53 (0.48) 1.45 (0.51) 0.59

Conners’ Teacher Rating ScalesConduct problem 1.11 (0.27) 0.98 (0.38) 0.19Hyperactivity 2.01 (0.34) 1.78 (0.46) 0.05Inattention–passivity 1.67 (0.27) 1.56 (0.41) 0.33Hyperactivity index 1.80 (0.36) 1.59 (0.49) 0.05

Sleep behavior 13.90 (7.67) 11.50 (9.23) 0.06

Statistical significance was defined as a p-value of <0.05.

Table 2. Comparison of the Conners’ Parent

Rating Scales, Conners’ Teacher Rating Scales,

and Sleep Behavior Before and After Treatment

in Massage Group

Variables Week 0 Week 8 p-value

Conners’ Parent Rating ScalesConduct problem 0.69 (0.31) 0.60 (0.26) 0.07Learning problem 1.86 (0.55) 1.76 (0.48) 0.38Psychosomatic 0.41 (0.45) 0.41 (0.32) 0.53Impulsivity–hyperactivity 1.62 (0.60) 1.44 (0.40) 0.16Anxiety 0.76 (0.53) 0.62 (0.56) 0.04*Hyperactivity 1.45 (0.51) 1.32 (0.41) 0.10

Conners’ Teacher Rating ScalesConduct problem 0.98 (0.38) 0.64 (0.35) 0.00*Hyperactivity 1.78 (0.46) 1.24 (0.50) 0.00*Inattention–passivity 1.56 (0.41) 1.18 (0.51) 0.00*Hyperactivity index 1.59 (0.49) 1.10 (0.49) 0.00*

Sleep behavior 11.50 (9.23) 5.33 (3.28) 0.00*

*Statistical significance was defined as a p-value of <0.05.

1358 PIRAVEJ ET AL.

and increase learning processes by reducing conduct prob-lems and anxiety in the massage group when compared tothe control group. After the completion of the study, weoffered the control group TTM.

Data from various studies have all shown the benefits ofmassages. For instance, two studies showed a reduction intouch aversion and stereotypic behaviors (e.g., rocking), in-creased attentiveness in a classroom situation, initiated touchmore frequently with their peers during playtime, showed lessfussing and crying, and self-stimulating behaviors.19,20 Eventhough we were able to detect a reduction in stereotypic be-haviors in our study, we did not see any significant increase inthe attention variable, in off-task and on-task behaviors, in theintervention group. It was possible that this discrepancy wasdue to the different techniques used, frequency, when thechildren were massaged, and length of the treatment sessions.In our study, we did not measure for touch aversion.

In another study, patients receiving massages becamemore lucid in their verbal communication, were more re-laxed and calmer, more communicative nonverbally, becamemore tolerant of touch, and the bonding between parentsand children improved significantly.25 However, the inves-tigators did note that the children’s reaction to touch therapywas varied; some children appeared to be more relaxedduring therapy while others were more alert, communica-tive, and their sleep patterns improved after therapy. Theauthors believed that these differences within the samegroup were short-lived despite its 8-week program. Theystated that the sessions may not have been long enough forlasting changes. We concurred that they should have hadmore sessions since they only provided a total of eighttraining sessions whereas we provided a total of 16 sessions.Even with a total of 16 sessions for 8 weeks, we were unableto see whether there were any other significant differencesbetween the massage and control groups aside from anxietyand conduct problems. Furthermore, we believed that an8-week program may not be sufficient enough to detectimprovement in other variables even though Field et al.were able to detect fewer autistic behaviors (touch aversion,off-task behavior, orienting to sounds, and stereotypic be-haviors),19 and an improvement in social relations that was

measured by the Autism Behavior Checklist (ABC) and theEarly Social Communication (ESC) Scales19 in 4 weeks with atotal of eight therapy sessions. We attributed this differenceto the questionnaires used.

Meanwhile, in another study, all the parents reported thatthey felt physically and emotionally closer to their childrenand subsequently that the relationship with their childrenhad been enhanced18 because they were able to display cuesfor touch. This emotional bonding was consistent with thefindings of other massage studies with children with a range

Table 3. Comparison of 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 ScalesConduct problem 0.59 (0.34) 0.63 (0.33) 0.27Learning problem 2.02 (0.56) 1.87 (0.53) 0.32Psychosomatic 0.43 (0.34) 0.39 (0.25) 0.50Impulsivity–hyperactivity 1.65 (0.65) 1.69 (0.57) 0.97Anxiety 0.62 (0.49) 0.73 (0.50) 0.17Hyperactivity 1.53 (0.48) 1.42 (0.42) 0.27

Conners’ Teacher Rating ScalesConduct 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 of <0.05.

Table 4. Comparison of the Mean Difference

of Conners’ Parent Rating Scales, Conners’ Teacher

Rating Scales, and Sleep Behavior Between Groups

VariablesControlgroup

Massagegroup p-value

Conners’ Parent Rating Scales

Conduct problemWeek 0 0.59 (0.34) 0.69 (0.31)Week 8 0.63 (0.33) 0.60 (0.26)Mean difference �0.04 (0.23) 0.09 (0.27) 0.03*

Learning problemWeek 0 2.02 (0.56) 1.86 (0.55)Week 8 1.87 (0.53) 1.76 (0.48)Mean difference 0.15 (0.65) 0.10 (0.53) 0.75

PsychosomaticWeek 0 0.43 (0.34) 0.41 (0.45)Week 8 0.39 (0.25) 0.41 (0.32)Mean difference 0.03 (0.27) �0.01 (0.40) 0.23

Impulsivity–hyperactivityWeek 0 1.65 (0.65) 1.62 (0.60)Week 8 1.69 (0.57) 1.44 (0.40)Mean difference �0.03 (0.79) 0.17 (0.58) 0.38

AnxietyWeek 0 0.62 (0.49) 0.76 (0.53)Week 8 0.73 (0.50) 0.62 (0.56)Mean difference �0.11 (0.61) 0.14 (0.32) 0.01*

HyperactivityWeek 0 1.53 (0.48) 1.45 (0.51)Week 8 1.42 (0.42) 1.32 (0.41)Mean difference 0.11 (0.45) 0.14 (0.41) 0.60

Conners’ Teacher Rating Scales

Conduct problemWeek 0 1.11 (0.27) 0.98 (0.38)Week 8 0.71 (0.26) 0.64 (0.35)Mean difference 0.39 (0.22) 0.33 (0.24) 0.21

HyperactivityWeek 0 2.01 (0.34) 1.78 (0.46)Week 8 1.49 (0.37) 1.24 (0.50)Mean difference 0.52 (0.34) 0.54 (0.35) 0.80

Inattention–passivityWeek 0 1.67 (0.27) 1.56 (0.41)Week 8 1.34 (0.36) 1.18 (0.51)Mean difference 0.32 (0.22) 0.38 (0.22) 0.28

Hyperactivity indexWeek 0 1.80 (0.36) 1.59 (0.49)Week 8 1.28 (0.40) 1.10 (0.49)Mean difference 0.52 (0.29) 0.49 (0.26) 0.74

Sleep BehaviorWeek 0 13.90 (7.67) 11.50 (9.23)Week 8 8.20 (6.83) 5.33 (3.28)Mean difference 5.70 (8.56) 6.17 (7.14) 0.85

*Statistical significance was defined as a p-value of <0.05.

EFFECTS OF THAI TRADITIONAL MASSAGE 1359

of disabilities.31 As for our study, we did not assess emo-tional bonding and attachment between the parents and theirautistic children because the massage was done by a pro-fessional. Yet we acknowledged that massage did affect thebehaviors of the children to the extent that it could improvetheir relationship with their parents. It would be interestingto see whether TTM was able to improve the children’s socialskills and communication with their peers and other familymembers.

Similar changes have also been noted for child and ado-lescent psychiatric inpatients diagnosed with adjustment anddepressive disorders. They showed significantly less de-pression and anxiety through measurements of salivary andurinary cortisol (associated with stress), increase in cooper-ation, reduction in night waking, and an increase in timespent sleeping after receiving massage therapies.28 Along thesame lines, another massage study did not rely only onsubjective data but more on objective data by focusing onbiological measurements such as electroencephalography(EEG) wave changes,32 and vagal activity by measuringheart rate.32 From EEG wave changes, Diego and colleagueswere able to show that massage therapies increased alertnessin autistic patients, especially on math tasks. The other studyusing vagal tones showed an increase of this measurementduring massage therapy, which was often associated withenhanced attentiveness and a more relaxed state.33 One of thedifferences between these studies and ours was that we didnot access for biological measurements, which could help sub-stantiate results not found significant obtained from the CRS.

Study limitations

The results from the CRS revealed that both groups wereable to reduce stereotypical behaviors. Since there were nodifferences reported by the teacher, we hypothesized that theCTRS might not be able to provide reliable data as comparedto the data from the CPRS. One possible explanation is thatthe teacher may not be familiar with the patients comparedto the parents and their observations might be limited. Be-sides, children were well known to behave differently whilein school from when they were at home with their parents.

As for the results obtained from the CPRS, it was shownthat in the control group, there was an improvement inlearning problems, psychosomatic, and hyperactivity vari-ables, whereas in the massage group, improvement was seenin five of six variables: conduct problems, learning problems,impulsivity–hyperactivity, anxiety, and hyperactivity. Inter-estingly, only conduct problems and anxiety were found tobe statistically significant in the massage group. The reasonfor this may be that the study’s sample size may have beentoo small to show any significant improvement in the othervariables and=or the CPRS may not be as reliable in ob-taining accurate information from the parents since theywere not blinded.

Also, we would like to point out that even though the CRSused in this study was not the most sensitive and reliablemeasurement in autistic patients, we continued to use theCRS based on another study.20 The questionnaire wastranslated into Thai and has been widely used in Thailand toassess behavioral problems in children.

Another limitation may be the duration of the study, be-cause it was difficult to assess any real behavioral changes in

a relatively short time even though three studies, conductedin 1 month,20 8 weeks,18 and 4 weeks,19 were able to showsome changes in the intervention group. Although in ourstudy we were not able to detect many significant behavioralchanges by 8 weeks, from our findings, TTM may be a usefultreatment option for autistic children.

Recommendations

We suggested that for future studies, the duration be ex-tended with crossover to avoid parent biases. Importantly, alarger sample size may demonstrate more visible significantimprovements in behavioral changes in the massage group.Furthermore, a 12-month follow-up interview or question-naire may reveal the longer-term outcomes of TTM. As forour study, we were unable to follow up our patients uponthe completion of the study since most of them were referredto the Centre, which will be a challenge for future studies.

Also, other scales should be used in conjunction with theCRS to determine whether other variables have improvedover time. Measurements from ABC and ESC will allow us toexpand on other variables that cannot be seen from just usingthe CRS. In addition, to avoid any biases in the results re-ported by the parents, teachers, or other people involved inthe study, videotaping the assessment sessions and the pa-tient’s sleeping pattern at home could help investigators ininterpreting the results.

It was important to emphasize that studies based solely onthe CRS, ABC, and ESC forms were limited by their subjec-tive nature and possible bias from both the parents andteachers. Therefore, objective data in the form of biologicalmeasurements studies are also needed to confirm the results.

Conclusions

Overall, we showed that this type of massage was able tosignificantly reduce conduct problems and anxiety in Thaiautistic children. Therefore, we concluded that TTM could beused 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 theparticipants, parents, and teachers for their involvement inthe study. Source of support: Grant #009=2549.

Disclosure Statement

No competing financial interests exist.

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Address correspondence to:Krisna Piravej, M.D.

Department of Rehabilitation MedicineFaculty of Medicine

Chulalongkorn UniversityBangkok 10330

Thailand

E-mail: knpiravej@hotmail.com

EFFECTS OF THAI TRADITIONAL MASSAGE 1361

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