Advance Access Publication 19 April 2006
Evaluating Effects of Aromatherapy Massage on Sleep in Childrenwith Autism: A Pilot Study
School of Psychology, University of Reading and Berkshire Healthcare NHS Trust, UK
Previous studies have found beneficial effects of aromatherapy massage for agitation in people withdementia, for pain relief and for poor sleep. Children with autism often have sleep difficulties, and itwas thought that aromatherapy massage might enable more rapid sleep onset, less sleep disruptionand longer sleep duration. Twelve children with autism and learning difficulties (2 girls and 10 boysaged between 12 years 2 months to 15 years 7 months) in a residential school participated in a withinsubjects repeated measures design: 3 nights when the children were given aromatherapy massage withlavender oil were compared with 14 nights when it was not given. The children were checked every30 min throughout the night to determine the time taken for the children to settle to sleep, the numberof 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 nightswhen the children were given aromatherapy massage and nights when the children were not givenaromatherapy massage. The results suggest that the use of aromatherapy massage with lavender oilhas 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
What is the Evidence for Aromatherapy?
of massage interventions alone have clearly established bene-ficial effects in chronic pain and situations where muscle
A recent review of the evidence for sensory stimulation in
relaxation is required (9). In an experimental study published
dementia care suggests that aromatherapy with lemon balm
last year, Kuriyama and co-workers were unable to identify
or lavender oil decreases agitation in patients with dementia
psychological effects of aroma over that of the massage alone,
(1). In other populations there are anecdotal reports of the
but did find physiological effects of aromatic oils over and
effectiveness of aromatherapy in calming people with autistic
above that of the carrier oil massage (9). In this investigation
spectrum disorders (2) and helping people sleep (3) and relax
we sought to demonstrate the effects of an aromatherapy
(4), although a systematic review of the field found little satis-
factory evidence for the claims (5). Nevertheless, one of thereview authors claimed that there was good evidence for arelaxing effect (6).
How could Aromatherapy Massage help
The situation is complicated by the fact that aromatherapy is
Children with Autism?
often delivered as a massage, and research studies have notidentified clearly which is the active ingredient (7,8). Trials
Children with autism have problems establishing a regulardiurnal pattern and in remaining asleep through the night(11–13). Some of these difficulties may be owing to over
For reprints and all correspondence: Dr Tim Williams, Department of
arousal or agitation. Given the effects of aromatherapy
Psychology, Berkshire Healthcare NHS Trust, 3/5 Craven Road,
massage in dementia and the wider claims of the effects of
Reading, RG1 5LF. Tel: þ44-118-931-5800; Fax: þ44-118-975-0297;
aromatherapy on sleep and arousal, we sought to examine
2006 The Author(s).
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License commons.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.
Evaluating aromatheraphy in autism
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 ofthe study was a Tuesday night, and aromatherapy was provided
on the second, third and fourth Thursday nights. This corre-sponds to an ABABAB design in which the A refers to nightswhen no aromatherapy was provided, and B refers to those
nights when aromatherapy was provided. Nights without arom-
atherapy can be regarded as baseline nights. The design doescarry with it the risk of improvements in sleep over time (a
Figure 1. Simplified diagram to show how aromatherapy might act on theproblems presented by people with autism. Aromatherapy can act both at
shifting baseline) if the effects of aromatherapy are cumulative.
the physiological/sensory level and at the level of the behavior problemsthemselves.
An experienced and trained aromatherapist delivered the
whether aromatherapy massage enabled an improved sleep
aromatherapy as a foot and leg massage using 2% lavender
pattern in children with autism. During waking hours the
oil in grapeseed oil on three separate evenings during the study
behavior of children with autism is characterized by repetitive
period at the school. The timing of each child's aromatherapy
activities such as stereotyped behavior, which are thought to be
was variable owing to other activities undertaken by the
the result of non-optimal levels (over and under arousal) of
child, but was always in the last 2 h before going to bed. All
arousal (Fig. 1). The putative mode of action of aromatherapy
the children were free to leave the aromatherapy sessions,
would be that it enabled an arousal level closer to the optimal,
although none did so. In order to accustom the children to
and hence, made sleep both easier to achieve and to maintain.
aromatherapy massage, it had been used as a leisure activity
The aims of the study were therefore to examine whether aro-
at various times during the school day in the previous term.
matherapy delivered through massage resulted in faster sleep
This ceased once the trial started. Thus, the intervention was
onset, longer sleep durations or fewer sleep interruptions.
not anxiety provoking for them.
Sleep onset, sleep duration and wakings from sleep are rou-
tinely recorded by waking night staff who checks each childevery 30 min throughout the night from 9 p.m. to 6 a.m. Sleep
All 12 children (2 girls and 10 boys) aged between 12 years
onset time is the time at which the children were first recorded
2 months to 15 years 7 months (mean age 14 years 1 month)
as being asleep. Sleep duration was calculated as the difference
from one unit of a residential school for children with autism
between the time the children were first recorded as being
were selected as participants for a trial of aromatherapy. The
asleep and the time the children woke up minus the time peri-
school checks diagnoses of autism against DSM-IV criteria
ods the children were awake. The number of wakings from
before the children are admitted. One boy had a diagnosis of
sleep was identified from the sleep records. Consecutive
Down's syndrome in addition to the diagnosis of autism. One
records of being awake were counted as a single waking.
girl was on carbamazepine and topiramate for control of herepilepsy and one of the boys was taking risperidone for control
of behavior. All the children had severe learning difficultiesand exhibited multiple repetitive behaviors. No children in
Complete data were available for 11 children. The analyses
the unit were excluded from entry to the trial, and the medica-
reported below are for Sunday through Thursday nights of
tion taken by the children did not change during the trial.
3 weeks. Data from 17 nights of a possible 24 nights were
All the children lived in one residential unit of the school
examined, of which 3 nights included aromatherapy massage
from Sunday to Thursday night inclusive. Only three of the
as part of the evening schedule. From the 24 possible nights,
children remained at the school for any of the Friday and
3 Fridays and Saturdays were excluded because only 3 children
Saturday nights during the study. Owing to these small num-
stayed for those nights; a further one night was excluded
bers it has not been possible to estimate the effect of remaining
from analysis because 2 children had been at home on that
for the weekend. Each child slept in a separate bedroom.
night (Fig. 2).
Although 12 children were considered as participants for the
There was little variability in the average time the children
trial, one became ill before the trial and remained at home
fell asleep (Fig. 2). The children fell asleep on average
for 10 of the possible 17 nights. His data has therefore been
between 10:30 p.m. and 11:15 p.m. A repeated measures
excluded from the analysis.
analysis of variance comparing nights with and without
Figure 2. Mean time first recorded as asleep and mean duration of sleep recorded on nights analyzed. The double headed arrows indicate nights when aromather-apy was administered.
Table 1. Sleep data for individuals whose sleep was analyzed in the study
The length of time the children were asleep was also subject
(sleep duration and sleep onset in hours–p.m.)
to a repeated measures analysis of variance which showed thatthere was no significant difference between the nights with and
Mean (SE) sleep onset time
Mean (SE) sleep duration
without aromatherapy (F ¼ 0.59; df ¼ 16, 160; P ¼ 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 ¼ 1411.4; df ¼ 1, 10; P < 0.001;
Table 1). The average number of hours slept per child ranged
between 6.85 and 8.88 h.
What did we Learn?
The results show that there were no statistically significant dif-ferences in the time the children went to sleep, the number of
aromatherapy revealed that there was no night with a statistic-
times they woke in the night and the length of time the children
ally significant different sleep onset time (Greenhouse–Geisser
slept that could be ascribed to the aromatherapy massage.
corrected F ¼ 1.27; df ¼ 4.15, 41.5; P ¼ 0.30). There was
It was well tolerated by the children. Each child's sleep
however a significant participant effect suggesting that there
pattern seemed to be stable although there were marked inter-
were systematic differences in the times at which individual
individual differences in both the duration of sleep and the
children fell asleep (F ¼ 59.83; df ¼ 1, 10; P < 0.001; mean
sleep onset time. In summary, where children with autism
sleep onset time range 9:30 p.m. and 11:40 p.m. Table 1).
and severe learning difficulties sleep well, aromatherapy
In total only 22 sleep interruptions were recorded. Seven
massage does not appear to offer benefits for sleep patterns.
of the children slept through all the nights without any inter-ruptions. Of the four remaining children, there were between
Limitations of the Study
0.11 and 0.5 interruptions per night (i.e. between one awaken-ing every nine nights and one every other night). There were
A better study would have allowed for evaluation of the intro-
no significant differences between the nights with and without
duction of the intervention. Our results also suggest that the
aromatherapy (Friedman test c2 ¼ 20.19; df ¼ 16; P ¼ 0.21).
sample size may have been too small to detect a significant
Evaluating aromatheraphy in autism
effect. Power calculations suggest that for an increase in sleep
would be useful. Alternatively, researchers might wish to con-
duration of 30 min, a sample of 160 children would need to be
sider the possibility of separating the aromatherapy and mas-
recruited. Alternatively, aromatherapy would need to produce
sage constituents of this intervention, since lavender oil mist
an increase in sleep duration of about 1 h 6 min to reach a
has already been shown to have beneficial effects on agitation
power of 0.80 at the 0.05 significance level. Our estimates of
in the elderly (8) and there is some research showing better
effect sizes may however have been skewed by the relatively
immune responses when aromatic essential oils are added
good sleep pattern the children showed. While it is possible
to massage procedures (9). There may be a priori reasons
that a more sensitive measure of sleep would enable smaller
for considering that some types of touch or aroma are non-
effects on sleep to be detected, the inter- and intra-individual
therapeutic for this population, which would enable a com-
variability is so great that this seems unlikely.
parative trial of different types of touch or aroma. Someconsideration should also be given to the possibility that this
Does this Study Agree with Others on
population might choose to have aromatherapy massage
because it is a pleasant sensation regardless of its effects onsleep, behavior or learning. Further trials should therefore con-
This study offers evidence on the effects of aromatherapy mas-
sider the implications for the quality of life of the participants,
sage on sleep patterns in children with comorbid learning dis-
by measuring behavioral disturbances, learning or quality of
abilities and autism. To our knowledge this article represents
life in this population.
the first attempt to evaluate the effects of aromatherapy mas-
Finally, consideration should be given to the optimum dura-
sage on the sleep of people with autistic spectrum disorders.
tion of the intervention. The use of an ABABAB design
It differs from previous studies by virtue of considering sleep.
requires both that aromatherapy has a rapid mode of action
A previous study with adults with learning disabilities simi-
and that it does not continue to have effects for more than a
larly noted little change in communication skills, as a result
few hours after it was administered. Support for this assertion
of the use of aromatherapy massage (14). In contrast, the litera-
comes from studies on sleep in the elderly (15) and joint atten-
ture on agitation in the elderly suggests that there are benefits
tion in children with autism (16). However, one study has
of the combined aromatherapy massage procedure, although
reported effects lasting several days for anxiety in children
these may not extend to pure aromatherapy [i.e. administration
with autism (16). A further risk is that the effect of aromather-
of the oil without massage or skin contact (8)].
apy is cumulative, and becomes evident only after several
These results are concordant with the systematic review of
administrations. As Fig. 2 shows that there appeared to be no
aromatherapy interventions reported by Cooke and Ernst (5).
significant gradient as would occur if a shifting baseline was
They concluded that the effects on anxiety were small and
involved. A much longer series of repeated administrations
transient, but cautioned that the trials were conducted with par-
might enable a more thorough investigation of these effects.
ticipants for whom conventional anxiolytic treatment was notwarranted. Similarly, the sleep patterns of the participants inthis study did not warrant the use of medication. Indeed, thesleep pattern of the children is better than that of children
in the community studied using actigraphic measures (13).
The author is grateful to all the children and staff at Priors
The children in this study went to sleep at about the same
Court School, who gave of their time to make this project
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 communitysamples where sleep problems are more prevalent.
What are Future Concerns for Analyses of
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Received February 19, 2006; accepted March 16, 2006
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