A Pilot Observational Study of an Acupressure/Acupuncture Intervention in Children with Autism Spectrum Disorder

Abstract

Objectives:

To determine whether children with autism spectrum disorder (ASD) would tolerate an acupressure/acupuncture intervention and whether parents would adhere to a twice-weekly, 8-week intervention protocol. Second, to further understand best measures to use to capture impact of intervention on behavioral and regulatory functions.

Design:

This is an observational pilot study with pre-, mid-, and postintervention measures.

Settings/location:

The intervention was carried out in a private practice office in a large metropolitan area.

Subjects:

A total of 10 children of ages 3–10 years with ASD and one of their parents participated.

Interventions:

A total of 16 biweekly treatment sessions of acupressure and/or acupuncture were carried out by a licensed acupuncturist, and a daily home-based acupressure intervention was carried out by a parent.

Outcome measures:

Attendance, tolerance of intervention, parent compliance with home program, and parent compliance in completing daily diary and five standardized measures of behavioral and regulatory functions pre-, mid-, and postintervention were recorded.

Results:

The 10 children in this observational study, collectively, tolerated the intervention and parents adhered to the 16 sessions, biweekly protocol, and home protocol, as well as completing daily diary and five standardized measures at three different time intervals. The five measurements appeared to be sensitive to behavioral and regulatory functions that may improve with this type of intervention.

Conclusions:

The results of this observational pilot study suggest that acupressure/acupuncture is a feasible intervention for children with ASD that merits rigorous evaluation through a randomized controlled trial.

Introduction

Autism spectrum disorder (ASD) is a chronic, complex developmental disorder with no single agreed-upon etiology or treatment approach. The increasing prevalence rate, which has most recently been estimated to be 1 in every 68 children, makes this disorder a serious public health concern.¹ Symptoms usually present during early childhood and endure throughout the lifespan.² Children with ASD often present with impaired behavioral and regulatory functions, including hyperactivity and attentional problems, irritability, and aggression; atypical sensory responses and gastrointestinal distress and sleep disturbances.^3

–6 For example, Rao and Landa found that nearly one-third of the parents of children with ASD in their study reported child behavioral problems consistent with DSM-IV criteria for attention deficit hyperactivity disorder (ADHD).⁷ Similarly, a recent review found that 68% of parents of children with ASD reported aggression toward family members.⁴ Moreover, across studies, between 40% and 80% of parents report sleep problems in their children with ASD, with the most commonly reported problems being associated with insomnia (e.g., long latency to initial sleep and night or early morning awakenings.⁷

Behavioral and regulatory problems associated with ASD are among the most frequent reasons families seek interventions for their children.⁵ Operant behavioral intervention strategies are the most commonly used intervention approaches for treating behavioral problems in children with ASD.⁸ Yet, behavioral therapies have met with only limited success in treating some problems of regulatory functioning, such as disturbances in sleep.⁷ When children with ASD do not respond, or have only a partial response to behavioral interventions, pharmacologic interventions are often introduced, either as a primary intervention or in combination with behavioral approaches.⁵

As an alternative to pharmacologic interventions, some parents have sought treatments classified as complementary and alternative medicine (CAM).^9
–11 The majority of studies focused on CAM use for ASD-related problems, particularly those conducted in the United States, involve diet modifications, vitamins, and food supplements. The CAM interventions of acupressure and acupuncture are rarely used as an intervention for children with ASD in the United States.^12,13

In contrast, these treatment modalities are the most commonly implemented interventions for children with ASD in Hong Kong.¹⁴ Acupressure and acupuncture interventions (hereafter collectively referred to as AIs) belong to the Traditional Chinese Medicine (TCM) paradigm used in China for centuries. TCM practitioners use herbal medicines and various mind and body practices, including acupressure and acupuncture. According to TCM, the rationale for the use of AIs in treating autism is that it provides a means of altering the disturbance of energy underlying the disorder, thereby restoring homeostasis and relief of many of the behavioral and regulatory symptoms commonly found in children with ASD.¹⁴ AI involves the manual stimulation of specific “acupoints” (specific loci of energy flow throughout the body) through firm pressure (acupressure) or the insertion of very fine needles, the size of a strand of hair (acupuncture). AIs include electroacupuncture, tongue acupuncture, scalp acupuncture, and total body acupuncture.^15

–18

AIs may provide a conceptual and practical complement to conventional behavioral and pharmacologic approaches used in the United States for treating behavioral and regulatory problems in children with ASD. Wong et al. at the University of Hong Kong are the most prolific researchers conducting clinical trials on the use of AIs with children with autism.¹⁴ Their research has provided empirical evidence supporting the efficacy of AI in improving the behavioral and regulatory functioning of children with autism, including the use of tongue acupuncture on improving cognition, language and symbolic play, electroacupuncture in improving language and self-care skills, and the use of total body acupuncture in improving language and social interaction.^16,18,19

Although there is a paucity of the documented use of AI with children with ASD in the Western literature, there are several anecdotal reports from practitioners as well as written reports from clinicians suggesting that AI may be a viable and effective complementary treatment option for children with ASD.^20,21 However, to date, there are no empirically validated studies to substantiate these reports. There is, however, a body of literature on the use of massage therapy on children with ASD that lends some credence to the use of AI as a treatment for ASD.

Massage therapy, which shares some of the important therapeutic components of AI, has been used therapeutically on children with ASD. During massage therapy, pressure is applied to specific areas and “pressure” points of the body that correlate with acupressure and acupuncture points and meridians. For example, Silva et al. reported a significant reduction in sensory impairment, and a significant improvement in social and basic living skills in children with ASD who received qigong massage therapy compared with those in an untreated control group.²² In a second study, children who received qigong massage therapy showed significantly greater improvement in social and language development as well as a significant decrease in autistic behaviors than those in a wait-list control group.²³ Using a parent-delivered massage therapy, Escalona et al. reported that children with ASD receiving the therapy demonstrated significantly greater improvement in emotionality, inattention, and impulsiveness, and sleep patterns than children in a control group.²⁴

Collectively, the aforementioned studies provide support for investigating the efficacy of AI in supporting the treatment of the regulatory and behavioral problems often present in children with ASD in the United States. As discussed in a recent review of the literature, there are several reasons why AI for children with ASD needs to be tested empirically in Western countries.²⁵ One reason is that all but one of the extant studies were conducted in Hong Kong, and the majority of these were conducted at one University. Thus, the generalizability of the results outside of this small homogeneous sample is unknown. Moreover, some researchers have noted that no published studies of negative findings using AIs have emerged from China; thus the published studies may not be representative of all studies conducted in Hong Kong.²⁶ Another potential barrier to the generalizability of the extant reports is that not all researchers use gold standard diagnostic tools of ASD and validated, standardized outcome measures that adhere to the same standards of peer-review used in the major journals of Europe and North America.

To the best of the Authors' knowledge, this study is the first to examine AIs on children with ASD in the United States. The primary goal of this pilot observational study was to determine whether children with ASD would tolerate an AI and families would adhere to a twice-weekly, 8-week intervention protocol. Secondary aims of the study were to investigate whether there is evidence that an AI is associated with improved behavioral and regulatory functioning in children with ASD and whether parents would report a reduction in parenting stress, and perceive an improvement in their relationship with their child following the parent-mediated component of the intervention.

Methods

This study was approved by the Johns Hopkins University Institutional Review Board before the collection of data, and all families gave written consent for participation.

Participants

Of 57 families who expressed interest in the study, 27 participated in a telephone screening interview. Of these 27 families, 16 came in to the autism center for eligibility testing; one child was ineligible to participate due to IQ falling below the eligibility criteria (IQ <70) and five families declined participation in the intervention. The final sample of families who participated in the study included 10 parent–child dyads; 8 of the children were males. Children ranged in age from 3 to 10 years (X = 6.2; SD = 2.4). Full Scale IQ ranged between 79 and 116 (X = 90.4; SD = 13.26). Eight of the parents were mothers and two were fathers. See Table 1 for individual child demographic characteristics.

Table 1.

Subject Characteristics

Subject No.	Age	Gender	FSIQ	IQ test
1	7	Male	79	DAS-II
2	9	Male	87	SB-5
3	10	Male	111	WISC-IV
4	6	Male	93	SB-5
5	6	Male	116	SB-5
6	3	Male	90	SB-5
7	4	Female	88	SB-5
8	3	Female	76	SB-5
9	8	Male	82	WISC-IV
10	6	Male	82	SB-5

FSIQ, full scale IQ composite score; IQ tests: DAS-II, Differential Abilities Scale, second edition; SB-5, Stanford–Binet, fifth edition; WISC-IV, Wechsler Intelligence Scales for Children, fourth edition.

Recruitment

Participants were recruited from a large metropolitan area through schools with autism classrooms, autism support groups, and autism shared databases through fliers, website postings, and newsletters.

Eligibility

Children were tested for study eligibility at a large autism center in the mid-Atlantic. Testing was conducted by masters and doctoral level clinicians trained in gold standard autism diagnostic assessments and standardized testing instruments.

Inclusion criteria

Children were required to be between 3 and 10 years of age and have a full-scale IQ of ≥70 on one of the following standardized measures of intelligence: (1) the Stanford–Binet Intelligence Scales, fifth edition (SB-5), (2) the Weschler Intelligence Scales for Children, fifth edition, or (3) the Differential Abilities Scales, second edition, and meet diagnostic criteria for an ASD using gold standard research measures.^27
–29 IQ testing had to have occurred within 2 years of the time of eligibility testing and test results had to be presented at the time of ASD eligibility testing. Children who had not received IQ testing, or had received the IQ test >2 years before eligibility were administered the SB-5 by the study clinicians at the time of ASD eligibility testing. To confirm a diagnosis of ASD using gold standard research measures, participants had to (1) meet diagnostic algorithm criteria for ASD or autism on the Autism Diagnostic Observation Schedule (ADOS)-Generic; (2) meet diagnostic algorithm criteria for autism on the Autism Diagnostic Interview-Revised; and (3) receive a clinical judgment of ASD or autism based on DSM-IV criteria.^2,30,31

Twenty percent of the ADOS assessments were randomly selected and rated by a second rater (other than the test administrator) to determine inter-rater reliability. Agreement between the two coders was determined by dividing the number of items in agreement by the total number of items on the ADOS; inter-rater agreement was 0.84. There was 100% inter-rater agreement that all participants met criteria for an ASD based on DSM-IV diagnostic criteria.²

Exclusion criteria

Children who had experienced a change in medication or nonmedical treatment within 4 weeks before the first session of the intervention were excluded from the study. Several children had a change in medication or school placement once intervention had started. In these cases, the Principal Investigator in consultation with an Advisory Committee, determined that the change would not affect the response to intervention and the children were deemed eligible to remain in the study. None of the participants started a new treatment therapy during the research protocol.

Procedure

Upon parent contact, a trained research assistant explained the study protocol, conducted a preliminary telephone screening interview, and obtained oral consent to mail a packet of preintervention questionnaires to the parent's home address. The child was then scheduled to come to the autism center for eligibility testing. Parents were instructed to complete the packet of questionnaires and return them to the research assistant at the time of the eligibility assessment (preintervention). Parents completed the same packet of questionnaires after eight sessions of acupressure (midintervention), and upon completion of the intervention (postintervention).

Intervention

The intervention was administered by an experienced, licensed acupuncturist, twice weekly, for 8 weeks, in a small private office, beginning with 4 weeks of acupressure therapy, followed by 4 weeks of acupressure/acupuncture. The acupuncturist individualized the intervention to address each child's behavioral profile based on a defined group of acupoints targeting the child's specific problem areas. Each session required ∼30 min to administer, with the exception of the first session that included a comprehensive evaluation (∼60 min). During the intervention, the child was asked to assume a supine position on the treatment table and the parent was seated in a chair next to the table. Acupressure was applied over the child's clothing, which was recommended to be loose fitting. Beginning with the first session, the acupuncturist demonstrated the acupressure strokes for home administration. Parents were instructed to administer the acupressure for ∼15 min at bedtime throughout the duration of the intervention protocol. Parents were provided with written procedures for home use, and were instructed not to perform the procedure if the child resisted on any particular night, but to continue to offer it every night thereafter. Parents were also instructed to complete a daily diary documenting their child's behavioral and regulatory functioning, as well as parental adherence and child compliance with the home acupressure protocol, and return the completed diaries to the interventionist on a weekly basis.

Acupuncture was introduced at midtreatment, after eight sessions of acupressure only. The interventionist continued to administer at least two acupressure strokes at the beginning of each acupuncture session. During the first acupuncture session, after receiving the acupressure strokes, the child was first introduced to the acupuncture needle, then, allowed to hold and examine it, followed by the interventionist demonstrating needling on either himself or the parent. Once the child was introduced to the acupuncture needle and procedure, the AI was administered to the child. If a child refused acupuncture, it was discontinued, and only acupressure treatment was administered for that session. Throughout the remainder of the intervention protocol, the mentioned procedure was repeated for reintroducing acupuncture at each subsequent session, but if refused by the child, only acupressure was administered in that session.

Measures

Child measures

Child behavior problems

The Behavior Assessment Scale for Children (BASC-2) was used as a measure of child problem behavior.³² The BASC-2 was normed with children 2–21 years of age, and consists of 12 individual scales that together yield a comprehensive measure of children's behavior across various settings. The 12 scales are categorized into 4 composite scales: Externalizing Problems (hyperactivity and aggression); Internalizing Problems (anxiety, depression, and somatization); Behavioral Symptoms Index (hyperactivity, aggression, depression, a typicality, withdrawal, and attention problems); and Adaptive Skills (adaptability, social skills, activities of daily living, and functional communication). The composite scales were used as the dependent variables (DVs) in this study.

Attentional problems

The parent report version of the Conners' Rating Scales Revised (CRS-R) was used to assess symptoms of ADHD as well as other related behavioral concerns.³³ The CRS-R was normed on over 8000 children of ages 3–17 years with ADHD and without psychologic problems, and is one of the most widely used standardized measures of ADHD in children. DVs from the CRS-R included Restlessness, Emotional Lability, Inattentiveness, and Hyperactivity/Impulsivity.

Adaptive and maladaptive behaviors

The parent version of the Pervasive Developmental Disorder Behavior Inventory (PDDBI) is designed to assess responsiveness to intervention in children with ASD.³⁴ The PDDBI is categorized into two broad domains of Approach/Withdrawal Problems and Receptive/Expressive Social Communication Abilities. It measures both adaptive (joint attention skills, pretend play, and referential gestures) and maladaptive (stereotyped behaviors, fears, aggression, social interaction deficits, and abnormal language) behaviors. The PDDBI was normed on children between the ages of 1.6 and 12.5 years. This study used the following composite scores as DVs: Repetitive/Pragmatic Problems, Approach/Withdrawal Problems, Expressive Social Communication, Receptive Social Communication, and the Autism Composite Scale.

Sleep problems

Assessment for sleep problems was performed using the children's sleep habits questionnaire (CSHQ), a 45-item, parent-reported questionnaire, normed on parents of children, ages 4–10 years.³⁵ The CSHQ assesses sleep problems common in school-age children and comprises eight subscales, including Bedtime Resistance, Sleep Onset Delay, Sleep Duration, Sleep Anxiety, Night Waking, Parasomnias (bedwetting, night terrors, sleep walking/talking, etc.), Sleep-Disordered Breathing, and Daytime Sleepiness. Specific DVs used in this study included Bedtime Resistance, Sleep Onset Delay, Sleep Anxiety, Night Wakefulness, and Parasomnias.

Parent measures

Parenting stress

The Parenting Stress Index was normed with parents of children of ages 1.6–12.5 years and is a widely used measure of parent stress in multiple domains.³⁶ The Parenting Stress Index (PSI) measures Child Domain sources of parent stress (Distractibility/Hyperactivity, Adaptability, Demandingness, Mood, and Acceptability) and Parent Domain sources of stress (Competence, Isolation, Attachment, Health, Role Restriction, Depression, and Spouse), as well as a providing a Total Life Stress composite score. DVs used in this study included Parent and Child Domain scores and the Total Life Stress composite score.

Daily diaries

Parents were asked to complete a 15-item daily diary designed by the acupuncturist participating in this study. The diary required the parent to document the daily administration of the home acupressure sessions, and assess the child's appetite, mood, sleep, and bowel behavior, as well as the quality of the parent–child relationship at three time points each day: morning, afternoon, and evening. Parents returned the diaries to the acupuncturist on a weekly basis.

Parent satisfaction with the intervention

A post-treatment parent/child nine-item satisfaction questionnaire was created by the first author to assess parents' overall satisfaction with the intervention. The questionnaire asked the parents about their satisfaction with the acupuncturist-delivered massage therapy, parent-delivered massage therapy, whether they would recommend the intervention to other ASD families, and whether they noticed improvement in their relationship with their child, in their child's school participation, peer relationships, and willingness to continue AI after completion of the study.

Results

Intervention compliance

All 10 participants completed the biweekly, 16-session treatment protocol. Due to child illness and/or family vacations, the number of weeks required to complete the treatment ranged from 8 to 11. All but one of the children transitioned successfully from acupressure to acupuncture, eight children at session 9, and one child at session 10. All 10 children were able to tolerate the acupressure component of the intervention, and all but one of them (90%) were able to tolerate both the acupressure and the acupuncture components. Parent diary reports revealed that parents maintained good compliance with the home-based acupressure regimen, with 8 of the 10 parents reporting that they administered the acupressure home treatment component at least five times per week.

Parent satisfaction with the intervention

Seven of the 10 parents (70%) completed the parent satisfaction questionnaire. Results revealed high overall satisfaction with the intervention. Six of these parents reported that the intervention improved their relationship with their child, and that they would continue to use acupressure stokes with their child at bedtime once the study ended, and would recommend AIs to other parents of children with ASD. Five of the seven families continued to have their child receive acupuncture treatment at their own expense for at least 1 month after the end of the study. The other two respondents reported that they would have liked to continue acupuncture treatment, but the distance to the acupuncturist's office was too far to travel (i.e., >60 miles).

Data analyses of the standardized DVs

All 10 families completed the entire packet of questionnaires at all three times of assessment. Parents completed missing data (skipped questions on the questionnaires) with a research assistant by phone. Thus, there were no missing data in the final data set. Because of the small sample size and large variation in age and IQ among the 10 participants in the study, a Shapiro–Wilks test of normality was conducted to test for normality of the distribution of scores. The results indicated that the sample was not normally distributed; thus nonparametric statistics (Wilcoxon signed-rank tests) were conducted to determine whether there were significant changes in the DVs across time of assessment (pre-, mid-, and post-treatment). The criterion for statistical significance was conservatively defined as p < 0.01 across the multivariate analyses to account for multiple comparisons. See Table 2 for mean scores and standard deviations for the DVs at all three times of assessment. Descriptive statistics (frequencies and percentages) were calculated with the data from the daily dairies and parent satisfaction questionnaires.

Table 2.

Mean Scores and Standard Deviations for the Dependent Variables at Pre-, Mid-, and Postintervention

	Preintervention	Midintervention	Postintervention
Behavioral assessment for children
Externalizing Problems	57.6 (11.20)	54.3 (7.04)	52.3 (4.10)
Internalizing Problems	47.6 (9.64)	43.6 (8.35)	43.8 (8.52)
Behavioral Symptoms	69.5 (9.46)	65.2 (4.26)	61.8 (3.10)^a
Adaptive Skills	30 (6.68)	32.3 (9.31)	35.5 (7.04)^a
Conners' Rating Scales Revised
Restlessness	71 (8.87)	65.8 (7.08)	62.3 (7.97)^b
Emotional Labilily	61.3 (12.12)	54.3 (9.90)	56.3 (8.86)
Inattention	71.5 (11.39)	66.1 (11.39)	60.4 (10.82)^b
Hyperactivity/Impulsivity	69.4 (9.75)	62.6 (7.44)	61.4 (8.99)^a
PDDBI
Repetitive/Pragmatic problems	50 (6.49)	48.6 (10.84)	46.7 (8.86)
Approach/Withdrawal problems	50.5 (6.83)	47.8 (9.54)	45.5 (7.68)
Expressive Social Communication	54.4 (4.80)	58.1 (5.37)	58.5 (6.67)^b
Receptive Social Communication	54.2 (4.52)	58.3 (5.10)	58.8 (6.66)^b
Autism Composite Score	48.6 (5.22)	44.6 (11.34)	41.8 (8.55)^a
Children's sleep habits questionnaire
Bedtime Resistance	7.4 (1.51)	7.7 (2.21)	7 (1.49)
Sleep Onset Delay	1.8 (0.79)	1.3 (0.68)	1.2 (0.42)
Sleep Anxiety	5.1 (1.29)	4.9 (1.20)	5 (1.32)
Night Wakefulness	4.4 (1.83)	4 (1.70)	4.2 (1.79)
Parasomnia	8.6 (1.27)	8.9 (1.37)	9.3 (1.94)
Parent Stress Inventory
Child Domain Stress	138.2 (10.63)	135.8 (11.94)	127.2 (12.52)^a
Parent Domain Stress	138.3 (36.13)	144.5 (24.45)	134.8 (31.21)
Life Stress	6.3 (3.64)	5.0 (3.65)	5.2 (3.97)

Trend; PDDBI, Pervasive Developmental Disorder Behavior Inventory.

p < 0.01.

Changes in regulatory and behavioral functioning from pre- to postintervention

Behavior Assessment Scale for Children

None of the subscales on the BASC-2 reached statistical significance for changes from pre- to postintervention using the adjusted p-value. There was a trend toward significant improvement in Behavioral Symptoms (Z = 2.14, p = 0.03) and Adaptive Skills (Z = 2.25, p = 0.02), from pre- to postintervention.

Conners' Rating Scales Revised

On the CRS-R, there was a significant reduction in Restlessness (Z = 2.5, p = 0.01), Inattention (Z = 2.6, p = 0.01), and a trend toward significance in Hyperactivity-Impulsiveness (Z = 2.2, p = 0.03) from pre- to postintervention. The change from pre- to postintervention in Emotional Lability was not statistically significant nor was a trend toward significance identified (p > 0.05).

Pervasive Developmental Disorder Behavior Inventory

On the PDDBI, there was significant improvement in Expressive Social Communication Abilities (Z = 2.61, p = 0.008) and Receptive Social Communication Abilities (Z = 2.67, p = 0.007) from pre- to postintervention, and a trend toward significant improvement in Overall Autistic Symptoms (Z = 2.3, p = 0.02). There was no significant improvement in Approach/Withdrawal Problems, Repetitive and Ritualistic Behaviors, or Pragmatic Problems at either mid- or postintervention (p's ≥ 0.05).

Children's sleep habits questionnaire

On the CSHQ, there was a trend toward a significant reduction in sleep onset delay at bedtime (Z = 2.20, p = 0.03) from pre- to postintervention, which became evident by midintervention (Z = 1.89, p = 0.06) before the introduction of acupuncture. There were no significant changes in Bedtime Resistance, Sleep Anxiety, Night Wakefulness, or Parasomnia, after acupressure or acupuncture treatment (p's > 0.05).

Parenting Stress Inventory

On the PSI, parents reported a trend toward a reduction in stress in the Child Domain from pre- to postintervention (Z = 2.07, p = 0.04), and the trend was apparent by midintervention before the introduction of acupuncture (Z = 2.19, p = 0.03). There was no significant change in Parent Domain Stress or Life Stress from pre- to postintervention (p's < 0.05)

Discussion

The primary goal of this pilot observational study was to determine whether AI was a potential intervention for children with ASD. A particularly positive outcome was the high compliance rate. Compliance was high across a number of variables, including attendance, completion of weekly diaries, and multiple questionnaires at three time points during the intervention, and adherence to a daily at-home intervention, as well as willingness to commute to and from the therapist's office in a heavily populated metropolitan area. A particularly impressive outcome was that all 10 families in this study were willing and able to complete an 8-week, twice-weekly intervention; thus, there was virtually a 0% attrition rate from the intervention and 100% completion rate of all outcome measures among those families who agreed to participate in the study with the exception of the satisfaction survey. The majority of parents also reported a positive response to the intervention and a belief that the intervention had a positive impact on their relationship with their child.

The secondary goal of this study was to investigate the feasibility of an AI for improving behavioral and regulatory functioning in children with ASD. The results of this study should be reviewed knowing that there was no control group and that all data were obtained through parent report, possibly reflecting bias. The results of the study suggest that AI may be a viable treatment option for reducing behavioral and regulatory problems frequently found in young children with ASD. Using validated, standardized dependent measures of behavior and regulatory functioning, this study found that children with ASD demonstrated significant improvement in restlessness and inattention, and a trend toward significant improvement in hyperactivity and impulsiveness, from pre- to post-treatment. These findings are consistent with those of Escalona et al.²⁴ who reported that children with ASD who received a parent-delivered massage therapy demonstrated significantly more improvement in inattention and impulsiveness than children in a control group. The improvement in attention may also be related to a reduction in parent stress starting at midintervention.

Unexpectedly, the most robust finding of the current pilot observational study was significant improvement in children's expressive and receptive social communication after the intervention. These findings are consistent with previous studies reporting significantly improved social communication after acupuncture, including language comprehension and social interaction.^14,18 However, they were unexpected because the acupoints selected for intervention in the current study were chosen to target areas of the body corresponding to behavioral and regulatory problems, not areas known to be involved with social communication. Nonetheless, these results are consistent with previous studies using massage therapy only, including improved social skills after two studies utilizing qigong massage intervention with children with ASD, and improved social relatedness during play with peers after a parent-delivered massage therapy.^22
–24 It was hypothesized that these improvements may have been related to improvement in regulatory functions that attenuated barriers to the children's autism-related communication and social difficulties.³⁷ Thus, these unexpected results are promising for further investigation.

Although not statistically significant, the current findings indicated some improvement in sleep delay after the intervention, which may be worth further investigation. Sleep problems are one of the most common co-occurring problems reported by parents of children with ASD, and delayed onset is one of the more frequently cited type of sleep problems brought to the attention of health professionals.⁷ After the intervention, parents were more likely to report that their child sometimes fell asleep within 20 min of going to bed compared with before the intervention when the majority reported that their child rarely fell asleep within this timeframe. This finding is consistent with Escalona et al.²⁴ who reported that a parent-delivered massage intervention, which is similar to the parent-administered acupressure strokes in this study, resulted in more deep sleep and fewer awakenings in children with ASD.

Of note, sensory processing concerns associated with ASD, particularly tactile, which had been anticipated to be problematic in AIs, did not manifest in the child participants in this study, with the exception of their general dislike of maintained deep pressure in one location. It should be noted that the initial acupressure strokes administered during the intervention were those that promote calming and quieting per Chinese Medicine theory. Further research with larger samples and comparison control groups is needed to further investigate these results. If AIs can facilitate a state of calm or contribute to factors that increase social relatedness and communicative functioning in children with ASD, the findings of this study have the potential to be of considerable clinical value. If an AI could help prime these more socially impaired children to be more easily engaged with interventionists, this may facilitate their receptiveness to intervention, and thereby increase their chances of an earlier or more positive response to treatment.

Taken together, the results of this study support other investigators' reports of positive findings related to AI for individuals with ASD, lending further credence to the viability of acupressure/acupuncture as an efficacious intervention option for the treatment of ASD in children.¹⁴ The findings that support the massage therapy studies are very intriguing and may suggest that acupressure therapy alone, without the use of acupuncture, may be beneficial as a treatment to address social, behavioral, and regulatory problems associated with ASD in children. Of further interest, an intervention reported by Escalona et al. was delivered by parents without an accompanying intervention delivered by a licensed acupuncturist, and demonstrated similar results. Thus, further research is needed to tease apart the effects of the various components included in the intervention protocol in this study.²⁴

There are several important limitations that arose during this preliminary study that should serve as a guide in designing future studies of AI for children with ASD. Most importantly to note, there was no control group in this preliminary pilot observational study and all results should be reviewed within this context. Second, recruitment for this study was difficult despite the large metropolitan geographic base from which participants were recruited. From multiple recruitment sources, only 57 families contacted the study coordinator and expressed interest in the study, and only 10 of these families actually participated in the study, resulting in a very small sample. Factors that families noted as contributing to recruitment difficulties included unfamiliarity and misunderstandings about acupressure and acupuncture, difficulty finding the time to commit to an 8-week, twice-weekly intervention due to busy schedules and long travel distances often through heavy traffic to and from the interventionist's office. These factors suggest that the families that participated may have been highly motivated/biased to participate in this particular study. Exploring the use of an acupressure-only intervention and perhaps having parents play a larger role through home-based delivery of the intervention might make a significant impact on subject recruitment for future studies as it would minimize the number of times participants would need to travel to the interventionist's site.

Another limitation of the study was the use of only one informant source (parents) in evaluating the outcome of the intervention and they could have a bias. Interestingly, parents did not report across-the-board improvements in their children, and there was consistency across parents in the domains of child functioning that were reported as improved. The findings of this study provide promise of efficacy of AI that should be further investigated in a randomized controlled trial. In future studies, additional informants (e.g., teachers), blind to timing of onset of AI or whether children received AI, should be included. It was planned to involve teachers as an additional informant group in this study, but the intervention occurred primarily during summer months when teachers were unavailable to complete questionnaires. Also helpful would be an observational pre- and postmeasure of child behavior that would be coded by research team members blinded to children's receipt of AI.

Conclusion

Given that behavioral and regulatory problems associated with ASD are among the most frequent reasons families seek interventions for their children, the results of this pilot observational study could potentially lay the ground work for future randomized controlled investigations of acupressure and/or acupuncture as viable treatment options for treating these problems.⁵ The results of this study suggest that AI can be tolerated by young children with ASD and that families are able to comply with an intensive intervention protocol, and that these interventions may have a positive impact on the parent–child relationship. Moreover, acupressure and acupuncture may be a viable nonpharmaceutical treatment option for children with ASD and concomitant ADHD symptomology, which warrants further investigation. Indeed, in a recent review of the literature, Wong et al. caution that “Currently there is no high-quality evidence to support the use of acupuncture for the treatment of ASD.”¹⁴ The findings of this pilot observational study will hopefully contribute to a growing foundation of research to support further investigation of acupressure and acupuncture as an alternative intervention or an intervention to be used in conjunction with existing therapies for children with ASD in the United States.

Footnotes

Acknowledgments

The authors thank Rebecca J. Landa, PhD, for her review of this article, Luther Kalb, MS for his contribution to the statistical analyses of the study, and the entire research staff at the autism center where this study was conducted. The authors also thank the families who participated in this research. This study was funded through Autism Speaks Grant No. 2949.

Author Disclosure Statement

No competing financial interests exist.

References

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American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: APA, 2000, Source Book 1.

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