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Tiny touch

As massage therapists, our biggest asset is touch. However, through age-old inaccuracies we often avoid the most touch-starved individuals.

October 14, 2014  By Tina Allen

As massage therapists, our biggest asset is touch. However, through age-old inaccuracies we often avoid the most touch-starved individuals.

tiny touch  
Nurturing touch through pediatric massage therapy can make a significant difference in the lives of children with autism and their families.


My goal has always been to touch the untouchable, whether it is an abandoned child with HIV in Vietnam, a child suffering from severe hospitalization or children on the autism spectrum. As massage therapists, we must push through the walls society has placed and reach out to all those who need and benefit from touch.

Children require nurturing touch to thrive, and for those on the autism spectrum, this is no different. It is important (in fact, required) to use specialized touch therapy, but by using this different approach, we can both relate to and reach this group of children.


Not only is reaching out to children in the autism spectrum important, it is urgent. We are in the midst of a global epidemic. Children are diagnosed at an ever-growing rate with one of many developmental disorders that include autism, attention deficit disorder and attention deficit hyperactivity disorder. In 1980, the ratio of autism diagnosis was one in 5,000; the most current data from the U.S. Centers for Disease Control says the ratio is now one in 88 children – with boys being affected four times as often as girls.

Understanding autism
One of the most popular tools in diagnosing autism spectrum disorder is The Diagnostic and Statistical Manual of Mental Disorders (DSM). This reference manual is used by mental health professionals and physicians in the United States to diagnose mental disorders. First published in 1952, it was referred to as DSM-I with subsequent versions following the numbered trend. The most recent version, DSM-5, was just released in May of 2013. Not only did this version increase the diagnostic categories by almost 12 per cent, it incorporated four previously separate disorders into one single condition: autism spectrum disorder (ASD).

According to the American Psychiatric Association, “ASD now encompasses the previous DSM-IV autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder (PDD) not otherwise specified.” This move has solidified the idea of a fluid spectrum for autism, which includes the idea that a patient’s severity and symptoms can “flow” along this spectrum.

Along with the addition of these disorders, the diagnosis requirements of ASD have also changed. The American Psychiatric Association defines ASD as “…characterized by 1) deficits in social communication and social interaction and 2) restricted repetitive behaviors, interests, and activities (RRBs). Because both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present.”   

According to the Autism Research Institute, Autism is a severe developmental disorder that begins at birth or within the first two-and-a-half years of life. Most children with autism are perfectly normal in appearance, but spend their time engaged in puzzling behaviours which are markedly different from those of neuro-typically developing children.

Usually diagnosed by the age of three, this complex developmental condition affects a child’s ability to develop normal language, form relationships with others, respond appropriately, is characterized by early onset of a lack of attachment, failure to cuddle as an infant, and an almost complete disassociation with the environment.

Autism, as we know it, is incurable and the behaviors associated with the disorder persist throughout the child’s lifetime.

Alex’s story
Alex is a funny, affectionate 10-year-old who loves to draw and has a brilliant sense of humour. He was diagnosed with PDD-NOS (atypical autism) when he was three years old. As a baby, he developed normally, but after he turned two, he started to display “quirks.” Alex was asked to leave two pre-schools due to his “meltdowns” which involved flapping his hands, standing on his toes, screeching and crying.

“We couldn’t go out to social gatherings, or even to the grocery store, until we obtained help from our local school district when he turned three,” says Catherine Podd, pediatric massage therapist and Alex’s mother. “He hated light touch, tags in shirts, noises from crowds of people, and bright lights in stores.”

When Alex was five, his first occupational therapist discovered he calmed down when she would give him a firm bear hug. This is just one of the tactical interventions that have been found to not only calm but may reduce sensory overload in children on the spectrum.  Hugging was commonly last on a caregiver’s list of “to-dos” when dealing with his meltdowns, but was a technique found to actually help.

To say children with autism do not like to be touched is false. Autism is characterized with sensory malfunction and dysfunction of the tactile system, often making a child averse to certain sights, sounds, smells or touches. Given that children with Autism have been reported to be opposed to physical contact, it is interesting that many massage therapists, and parents, are finding great success in the use of massage therapy for those considered to be on the spectrum.

According to Dr. Dustin P. Wallace, assistant professor of Pediatrics Integrative Pain Management Clinic and Division of Developmental and Behavioral Sciences at The Children’s Mercy Hospitals and Clinics, “People with ASD often struggle with increased sensitivity to sensory stimuli, including tactile stimulation, and massage provides a comforting experience of tactile stimulation, while also helping to decrease pain amplification through desensitization.”

Carter’s story
Carter was diagnosed with Asperger’s syndrome in July 2008, shortly after his fifth birthday. In December 2009, he was diagnosed with ADHD. Carter has always been full of energy and rarely napped, even as a baby. His interests never included Lego or Thomas the Tank Engine. Early on, his obsessions were animals and the alphabet. Carter would line everything up alphabetically and made sure all his toys were in order.

“He [Carter] could tell you just about anything you wanted to know about any animal, including their scientific name,” says Angela Ajamie, massage therapist from Massachusetts and Carter’s mother. “When he was three, he spelled (with blocks) ALBATROSS on the living room floor. When I asked him how he knew how to spell that word, he answered: ‘I read it in the dictionary.’ Carter could read Dr. Seuss books by the age of two-and-a-half.”

Communication is relative, especially on the spectrum. Often, a child may be unable to communicate in a way we understand, but this has no bearing on the child’s IQ or educational abilities. As massage therapists, there are many ways we can assist; massaging of the face to help atrophied muscles, providing pictures which can be used to form sentences or, in Carter’s case, provide blocks so he can spell out his needs.

The challenge – Pediatric massage therapists are taught to meet children at their level and help them to be able to connect with the world around them.

“In the medical setting, children are often times already withdrawn, scared and maybe confused,” says Jennifer Townsend, neurologic therapy fellow at Dell Children’s Medical Center. “The child with Autism has all of these reactions in addition to trying to take in new sensory information. It can be very difficult for them to make new connections with people while in this new setting.”

For each child, there is no exact protocol to follow, which means the same massage strokes, activities, or even the songs we sing, may change from moment to moment. Communication and engagement, imperatives in a massage session, are often stressful for the child. Since each session should always be child-directed we can provide alternative methods for communication; this may be a series of gestures, hand placements, non-verbal gestures or non-language sounds. Each child’s needs, whether on the spectrum or not, should always be respected and attended to.

“The individuality and uniqueness of each child is one of the biggest challenges in working with children on the autism spectrum, and also one of the biggest rewards,” says Elizabeth Schroeder, occupational therapist and massage therapist at Children’s Mercy Hospital in Kansas City. “These differences make it nearly impossible for there to be any one trick or treatment that works with all children on the spectrum. Each therapy session looks and feels different between each child and between each session for one child.”

Nicole’s story
Nicole is a beautiful young woman with a smile that can light up any room. She is living with Rett syndrome, a neural developmental disorder that causes problems with cognition, emotions, sensory systems, autonomic and motor functions.

“Massage warms her muscles and connecting tissues to help relieve some of the discomfort caused by immobility,” says her mom Wende Lancaster, a massage therapist from Texas. “Working her muscles helps Nicole relax thoroughly, increases her circulation, aides her hypotonia and gastrointestinal issues.”

The impact that autism spectrum disorder has on children cannot be easily defined, many have trouble with atrophied muscles, upset stomachs, trouble sleeping, and even gastrointestinal issues. The good news is that massage can help in all of these situations. Simple strokes on the stomach can help relieve constipation, gas and discomfort. Touch therapy contributes to more restful sleep, including less sleep disruption and longer sleep duration.

Collaborative approach – Educating children, parents and other health-care professionals is what makes a therapeutic session successful. Working with a pediatric client means you not only work with the client but their parents as well.

“Many children won’t just hop up on the table and tell you their ailments,” says Podd. “A pediatric massage therapist can make a parent and child more comfortable, take time with the child, and use different techniques that might help the child feel at ease.”

Collaborating doesn’t stop with parent and child but often includes their health-care team. Using a strategy to best ensure a unified approach is essential. This can include being respectful of specific culture, time as well as priorities for the client, family and team.

“In regards to working with health-care team members, therapists should be prepared to educate the team about massage,” says Schroeder. “Many providers assume massage is an adult activity to do while at a spa. It is the therapist’s job to educate the team about massage, touch and how they can use it appropriately in their own tasks with the child.”

Individual approach – “Working with children gives you a different point of view when you are in the treatment room,” says Podd. “It might take weeks to even get a child on the table, but it teaches you to slow down and respect that space again.”

For children on the spectrum, the therapist should be aware of the child’s possible anxiety about being touched. This stems from tactile hypersensitivities and previous touch being interpreted as painful or confusing. Therapists should move cautiously and respect the child’s cues. Take your time to recognize a child’s likes and dislikes associated with types of touch, textures, sensory considerations and type of lubricant.

Whenever we use massage, we must first have permission. Children may not always provide direct eye-to-eye contact or a verbal “Yes.” Establishing non-verbal communication and using slow transitions is important. If a child does not prefer direct eye-to-eye contact, do not force it, as it may feel confrontational.

For many children with autism, there is susceptibility to sensory overload, and they may lack feeling or awareness. It is important to begin with still hands and gradually work deeper.

No two children with the same diagnosis will likely present exactly the same. Slow down, take your time, and enjoy connecting with kids.

The benefits
Pediatric massage provides not only a positive experience, but also lifelong benefits. The cost of a child’s lifelong care can be reduced by as much as two-thirds with early diagnosis and appropriate interventions, such as pediatric massage therapy.

“Massage therapy is very helpful for our patients with autism spectrum disorders, sometimes uniquely so,” says Dr. Wallace of The Children’s Mercy Hospitals and Clinics. “Many of the conditions we treat involve pain amplification, which is when nerves ‘over-report’ and even normal sensations can feel painful.”

Children on the spectrum frequently appear anxious due to a variety of reasons. This anxiety and stress can be contagious within the family, and can affect how parents and siblings interact with the child on the spectrum.

Published studies suggest that massage therapy may decrease cortisol levels and increase oxytocin levels, which directly correlate to decreased stress, anxiety and nervousness.

Over time, children who receive massage become more spatially aware and have better body awareness. This safe, nurturing touch, along with regular sensory integration, is beneficial in reducing inattentiveness, touch aversion and withdrawal.


Tina Allen is the founder of Liddle Kidz Foundation and has led the creation of pediatric massage programs in leading medical institutions including the Mayo Clinic. She travels 365 days a year in a tour bus with her husband and their son, Otis, sharing the benefits of nurturing touch.

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