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Evid Based Complement Alternat Med. 2006
September; 3(3): 373–377. Published
online 2006 April 19. doi: 10.1093/ecam/nel017.
Copyright [copyright]
2006 The Author(s)
Evaluating Effects of Aromatherapy Massage on Sleep in
Children with Autism: A Pilot Study
Tim I. Williams
School of Psychology, University of Reading and
Berkshire Healthcare NHS Trust, UK
Received February 19, 2006; Accepted March 16, 2006.
This is an Open Access article distributed under the terms of the
Creative Commons Attribution Non-Commercial License
(http://www.pubmedcentral.nih.gov/redirect3.cgi?&&reftype=extlink&artid=1513142&iid=132889&jid=241&&http://creativecommons.org/licenses/by-nc/2.0/uk/)
which permits unrestricted non-commerical use, distribution, and
reproduction in any medium, provided the original work is properly
cited. |
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Abstract
Previous studies have found beneficial effects of aromatherapy massage
for agitation in people with dementia, for pain relief and for poor sleep.
Children with autism often have sleep difficulties, and it was thought
that aromatherapy massage might enable more rapid sleep onset, less sleep
disruption and longer sleep duration. Twelve children with autism and
learning difficulties (2 girls and 10 boys aged between 12 years 2 months
to 15 years 7 months) in a residential school participated in a within
subjects repeated measures design: 3 nights when the children were given
aromatherapy massage with lavender oil were compared with 14 nights when
it was not given. The children were checked every 30 min throughout the
night to determine the time taken for the children to settle to sleep, the
number of awakenings and the sleep duration. One boy's data were not
analyzed owing to lengthy absence. Repeated measures analysis revealed no
differences in any of the sleep measures between the nights when the
children were given aromatherapy massage and nights when the children were
not given aromatherapy massage. The results suggest that the use of
aromatherapy massage with lavender oil has no beneficial effect on the
sleep patterns of children with autism attending a residential school. It
is possible that there are greater effects in the home environment or with
longer-term interventions.
Keywords: Aromatherapy, massage, autism, sleep,
children |
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What is the
Evidence for Aromatherapy?
A recent review of the evidence for sensory stimulation in dementia
care suggests that aromatherapy with lemon balm or lavender oil decreases
agitation in patients with dementia (1). In other populations there are
anecdotal reports of the effectiveness of aromatherapy in calming people
with autistic spectrum disorders (2) and helping people sleep (3) and
relax (4), although a systematic review of the field found little
satisfactory evidence for the claims (5). Nevertheless, one of the review
authors claimed that there was good evidence for a relaxing effect
(6).
The situation is complicated by the fact that aromatherapy is often
delivered as a massage, and research studies have not identified clearly
which is the active ingredient (7,8). Trials of massage interventions
alone have clearly established beneficial effects in chronic pain and
situations where muscle relaxation is required (9). In an experimental
study published last year, Kuriyama and co-workers were unable to identify
psychological effects of aroma over that of the massage alone, but did
find physiological effects of aromatic oils over and above that of the
carrier oil massage (9). In this investigation we sought to demonstrate
the effects of an aromatherapy massage.
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How could
Aromatherapy Massage help Children with Autism?
Children with autism have problems establishing a regular diurnal
pattern and in remaining asleep through the night (11 --13). Some of these
difficulties may be owing to over arousal or agitation. Given the effects
of aromatherapy massage in dementia and the wider claims of the effects of
aromatherapy on sleep and arousal, we sought to examine whether
aromatherapy massage enabled an improved sleep pattern in children with
autism. During waking hours the behavior of children with autism is
characterized by repetitive activities such as stereotyped behavior, which
are thought to be the result of non-optimal levels (over and under
arousal) of arousal (Fig. 1). The putative mode of action of aromatherapy
would be that it enabled an arousal level closer to the optimal, and
hence, made sleep both easier to achieve and to maintain. The aims of the
study were therefore to examine whether aromatherapy delivered through
massage resulted in faster sleep onset, longer sleep durations or fewer
sleep interruptions.
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Methods
Participants
All 12 children (2
girls and 10 boys) aged between 12 years 2 months to 15 years 7 months
(mean age 14 years 1 month) from one unit of a residential school for
children with autism were selected as participants for a trial of
aromatherapy. The school checks diagnoses of autism against DSM-IV
criteria before the children are admitted. One boy had a diagnosis of
Down's syndrome in addition to the diagnosis of autism. One girl was on
carbamazepine and topiramate for control of her epilepsy and one of the
boys was taking risperidone for control of behavior. All the children had
severe learning difficulties and exhibited multiple repetitive behaviors.
No children in the unit were excluded from entry to the trial, and the
medication taken by the children did not change during the trial.
All the children lived in one residential unit of the school from
Sunday to Thursday night inclusive. Only three of the children remained at
the school for any of the Friday and Saturday nights during the study.
Owing to these small numbers it has not been possible to estimate the
effect of remaining for the weekend. Each child slept in a separate
bedroom. Although 12 children were considered as participants for the
trial, one became ill before the trial and remained at home for 10 of the
possible 17 nights. His data has therefore been excluded from the
analysis.
Design
A within subjects design was
used. Aromatherapy massage was administered on Thursday nights. The period
of the study was 24 days, beginning on the first night of the term and
finishing after three administrations of aromatherapy. The first night of
the study was a Tuesday night, and aromatherapy was provided on the
second, third and fourth Thursday nights. This corresponds to an ABABAB
design in which the A refers to nights when no aromatherapy was provided,
and B refers to those nights when aromatherapy was provided. Nights
without aromatherapy can be regarded as baseline nights. The design does
carry with it the risk of improvements in sleep over time (a shifting
baseline) if the effects of aromatherapy are cumulative.
Procedure
An experienced and trained
aromatherapist delivered the aromatherapy as a foot and leg massage using
2% lavender oil in grapeseed oil on three separate evenings during the
study period at the school. The timing of each child's aromatherapy was
variable owing to other activities undertaken by the child, but was always
in the last 2 h before going to bed. All the children were free to leave
the aromatherapy sessions, although none did so. In order to accustom the
children to aromatherapy massage, it had been used as a leisure activity
at various times during the school day in the previous term. This ceased
once the trial started. Thus, the intervention was not anxiety provoking
for them.
Measures
Sleep onset, sleep duration
and wakings from sleep are routinely recorded by waking night staff who
checks each child every 30 min throughout the night from 9 p.m. to 6 a.m.
Sleep onset time is the time at which the children were first recorded as
being asleep. Sleep duration was calculated as the difference between the
time the children were first recorded as being asleep and the time the
children woke up minus the time periods the children were awake. The
number of wakings from sleep was identified from the sleep records.
Consecutive records of being awake were counted as a single waking.
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Results
Complete data were available for 11 children. The analyses reported
below are for Sunday through Thursday nights of 3 weeks. Data from 17
nights of a possible 24 nights were examined, of which 3 nights included
aromatherapy massage as part of the evening schedule. From the 24 possible
nights, 3 Fridays and Saturdays were excluded because only 3 children
stayed for those nights; a further one night was excluded from analysis
because 2 children had been at home on that night (Fig. 2).
There was little variability in the average time the children fell
asleep (Fig. 2). The children fell asleep on average between 10:30 p.m.
and 11:15 p.m. A repeated measures analysis of variance comparing nights
with and without aromatherapy revealed that there was no night with a
statistically significant different sleep onset time (Greenhouse --Geisser
corrected F = 1.27; df = 4.15, 41.5; P = 0.30). There
was however a significant participant effect suggesting that there were
systematic differences in the times at which individual children fell
asleep (F = 59.83; df = 1, 10; P < 0.001; meansleep
onset time range 9:30 p.m. and 11:40 p.m. Table 1).
In total only 22 sleep interruptions were recorded. Seven of the
children slept through all the nights without any interruptions. Of the
four remaining children, there were between 0.11 and 0.5 interruptions per
night (i.e. between one awakening every nine nights and one every other
night). There were no significant differences between the nights with and
without aromatherapy (Friedman test [chi]2 = 20.19; df = 16;
P = 0.21).
The length of time the children were asleep was also subject to a
repeated measures analysis of variance which showed that there was no
significant difference between the nights with and without aromatherapy
(F = 0.59; df = 16, 160; P = 0.89). The children slept
on average between 7.25.and 8.25 h per night (Fig. 2). There was however a
statistically significant child effect suggesting that different children
had significantly different sleep durations (F = 1411.4; df = 1,
10; P < 0.001; Table 1). The average number of hours slept per
child ranged between 6.85 and 8.88 h.
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Discussion
What did we Learn?
The results show
that there were no statistically significant differences in the time the
children went to sleep, the number of times they woke in the night and the
length of time the children slept that could be ascribed to the
aromatherapy massage. It was well tolerated by the children. Each child's
sleep pattern seemed to be stable although there were marked
inter-individual differences in both the duration of sleep and the sleep
onset time. In summary, where children with autism and severe learning
difficulties sleep well, aromatherapy massage does not appear to offer
benefits for sleep patterns.
Limitations of the Study
A better
study would have allowed for evaluation of the introduction of the
intervention. Our results also suggest that the sample size may have been
too small to detect a significant effect. Power calculations suggest that
for an increase in sleep duration of 30 min, a sample of 160 children
would need to be recruited. Alternatively, aromatherapy would need to
produce an increase in sleep duration of about 1 h 6 min to reach a power
of 0.80 at the 0.05 significance level. Our estimates of effect sizes may
however have been skewed by the relatively good sleep pattern the children
showed. While it is possible that a more sensitive measure of sleep would
enable smaller effects on sleep to be detected, the inter- and
intra-individual variability is so great that this seems unlikely.
Does this Study Agree with Others on
Aromatherapy Massage? This study offers evidence on the effects of
aromatherapy massage on sleep patterns in children with comorbid learning
disabilities and autism. To our knowledge this article represents the
first attempt to evaluate the effects of aromatherapy massage on the sleep
of people with autistic spectrum disorders. It differs from previous
studies by virtue of considering sleep. A previous study with adults with
learning disabilities similarly noted little change in communication
skills, as a result of the use of aromatherapy massage (14). In contrast,
the literature on agitation in the elderly suggests that there are
benefits of the combined aromatherapy massage procedure, although these
may not extend to pure aromatherapy [i.e. administration of the oil
without massage or skin contact (8)].
These results are concordant with the systematic review of aromatherapy
interventions reported by Cooke and Ernst (5). They concluded that the
effects on anxiety were small and transient, but cautioned that the trials
were conducted with participants for whom conventional anxiolytic
treatment was not warranted. Similarly, the sleep patterns of the
participants in this study did not warrant the use of medication. Indeed,
the sleep pattern of the children is better than that of children in the
community studied using actigraphic measures (13). The children in this
study went to sleep at about the same time as the sleepless group in Wiggs
and Stores (13), but showed rather less waking in the night. It might be
better, therefore, to research aromatherapy massage in community samples
where sleep problems are more prevalent.
What are Future Concerns for Analyses of
Aromatherapy? The fact that the children tolerated the aromatherapy
massage suggests that further investigations of aromatherapy massage could
be undertaken with this group. Future studies will have to take into
account general concerns about the most appropriate design for a trial of
aromatherapy massage. Any treatment that involves bodily contact cannot
easily be subject to a double blind trial because the recipient will
inevitably be aware that they are being touched. The materials used also
leave traces on the skin of the recipient, and the aromatic constituent is
easily detected. In order to ensure adequate blinding of the assessors,
video or automated data gathering methods (e.g. actimeters, which are
small devices the size of a wrist watch) would be useful. Alternatively,
researchers might wish to consider the possibility of separating the
aromatherapy and massage constituents of this intervention, since lavender
oil mist has already been shown to have beneficial effects on agitation in
the elderly (8) and there is some research showing better immune responses
when aromatic essential oils are added to massage procedures (9). There
may be a priori reasons for considering that some types of touch
or aroma are non-therapeutic for this population, which would enable a
comparative trial of different types of touch or aroma. Some consideration
should also be given to the possibility that this population might choose
to have aromatherapy massage because it is a pleasant sensation regardless
of its effects on sleep, behavior or learning. Further trials should
therefore consider the implications for the quality of life of the
participants, by measuring behavioral disturbances, learning or quality of
life in this population.
Finally, consideration should be given to the optimum duration of the
intervention. The use of an ABABAB design requires both that aromatherapy
has a rapid mode of action and that it does not continue to have effects
for more than a few hours after it was administered. Support for this
assertion comes from studies on sleep in the elderly (15) and joint
attention in children with autism (16). However, one study has reported
effects lasting several days for anxiety in children with autism (16). A
further risk is that the effect of aromatherapy is cumulative, and becomes
evident only after several administrations. As Fig. 2 shows that there
appeared to be no significant gradient as would occur if a shifting
baseline was involved. A much longer series of repeated administrations
might enable a more thorough investigation of these effects.
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Acknowledgments
The author is grateful to all the children and staff at Priors Court
School, who gave of their time to make this project successful.
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