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Citymarshall.co.ukAdvance Access Publication 19 April 2006 eCAM 2006;3(3)373–377 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 Sleep data
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 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.
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Received February 19, 2006; accepted March 16, 2006
Medical Technology SA Volume 25 No. 1 June 2011 Peer reviewed rEviEW PATHOGENESIS AND FUTURE TREATMENTS OF SYSTEMIC LUPUS ERYTHEMATOSUS: THE ROLE OF CYTOKINES AND ANTI-CYTOKINES?W. J. MauleUniversity of Johannesburg, Department of Biomedical Technology, Faculty of Health Sciences, South Africa.email: [email protected] tel: +27 (0)11 559 6265 fax: +27 (0)11 559 6558