Effect of Feet Reflexology on Autism Symptoms and Constipation in Children with Autistic Spectrum Disorder

The autistic Spectrum Disorder represents specific distinguishable symptoms that have frequent concurrent conditions and constipation is the most frequent. It requires an effective non-disturbing management. Reflexology is a widely used technique and documented as a useful nursing intervention. This study aimed to determine the effect of feet reflexology on autism symptoms and constipation in children with ASD. Subject and Methods: a quasi-experimental design was utilized and it conducted at the psychiatric outpatient clinic, Menoufia University hospital. A purposive sample of 30 children was recruited. Two instruments were utilized: Autism Treatment Evaluation Checklist (ATEC) and Constipation Assessment Questionnaire (CAQ). Results: children had lower mean scores and severity of autism symptoms on post-intervention compared to pre-intervention speech/communication, sociability, sensory/cognitive, health/physical/behavior subdomains and the total ATEC score. The mean total score of constipation symptoms was lower on post-intervention compared to pre-intervention (35.93±16.04, 40.23±17.51 respectively) and there was a significant correlation (R=0.858) at the 0.01 level of significance between constipation and the severity of autism symptoms on post-intervention. Conclusion: the study concluded that autistic children exposed to feet reflexology experienced lower mean scores of autism symptoms and less severity of constipation compared to pre reflexology massage. There was a significant correlation between constipation and the severity of autism symptoms on post-intervention. Recommendation: Feet reflexology should be integrated as a part of routine daily care for autistic children and courses that enable nurses to obtain a certification in reflexology are needed.


Introduction
Autistic Spectrum Disorder (ASD) is a lifelong disability affects the overall health of children that impose a burden on the family and health care system (Fletcher, et al., 2012).Recently, the American Psychiatric Association (2013) clarified that ASD encompassed numerous types including atypical autism, childhood disintegrative disorders, pervasive developmental disorder not otherwise specified, and Asperger's syndrome.
ASD is the second most common developmental disability among children and there is a growing rate of newly diagnosed children with autism ranges from 10-17% each year (Iannuzzi, et al., 2018).It affects 1 in 59 American children and four folds more prevalent among boys than girls (Baio et al., 2018).However, the estimated number of autistic children in Egypt was 140.000 children and approximately, affects one child in 870 children (Haffiz, 2007;Elbahnasawy, 2011).
An autistic spectrum disorder is a complex developmental disorder of the brain that is characterized by a broad range and severity of intellectual and behavioural deficits (Hockenberry et al., 2013; American Psychiatric Association, 2013).Autism symptoms display specific distinguishable symptoms.The dominant feature of ASD is the social communication dysfunctions (Park et al., 2016) which include impairment of the verbal and nonverbal communication.Another hallmark characteristic of ASD is a repetitive stereotyped behavior (Kotagal, Broomall, 2012).
Furthermore, there are numerous health conditions frequently concurrent with autism.Gastrointestinal symptoms have been reported in frequent studies with a wide prevalence ranged from 9% to 91% which relies on the severity of gastrointestinal dysfunction (Buie et al., 2010;Ghoneim, 2018).Among these symptoms, constipation is the most frequent gastrointestinal symptom (Ibrahim et al., 2009;Nikolov, et al, 2009;McElhanon et al, 2014).
Approximately, 36 % of children with ASD had constipation.Although constipation in autistic spectrum disorder is a critical issue, its causes remain embarrassing (Afzal et al., 2003).However, there are numerous suggested explanations such as inherited gut abnormality, the neurotoxic bacteria, and serotonin abnormalities.Other studies claimed that constipation in autistic spectrum disorder is related to the food selectivity feature of autistic children that result in restrictive diets and low fibre intake (Ibrahim et al., 2009;Maenner et al., 2012).
Constipation has negative consequences on the children include abdominal distension, discomfort, pain, anorexia, malaise and angry mood (National Collaborating Centre for Women's and Children's Health-UK, 2010).In addition, straining during defection may result in faecal impaction, haemorrhoids (Potter and Perry, 2001).The reliability of the tool was reported by Cronbach's Alpha test r = 0.80.

Validity and Reliability:
Tools were developed by the researcher for data collection after a review of past and current literature, local and international related literature using books, articles, periodicals, and magazines.Then, the tools were submitted to a panel of three pediatric nursing experts for the validity purpose.Tools reliability was tested by Cronbach's coefficiency alpha.

Ethical Consideration:
For the protection of human rights, the researchers obtained informed consent from the third year pediatric nursing students after a clear explanation of the objectives of the study, its importance, safety and confidentiality for the participants.

Pilot study:
A pilot study was carried out on 10 students to test the practicability, applicability, and feasibility of items in data collection tools.No modifications were done.The sample of the pilot study was excluded from the total sample.

Procedure:-
1. Prior to data collection, written permission to carry out the study was obtained from the manager of the Menoufia University hospital after explaining the purpose of the study and methods of data collection.
by the study instruments.

Statistical Analysis:
The collected data were categorized, tabulated, and summarized.Data were computerized and analyzed by SPSS version 20 (SPSS Inc., Chicago, IL, USA).Two types of statistics were done descriptive and analytical to examine the research hypothesis.Descriptive statistics were done using percentage (%), mean and standard deviation (SD).Analytical statistics used in the study were Chi-Squared (χ 2 ), ANOVA test and Pearson correlation test.
Statistically, a significant difference was found if P <0.05.

Limitation of the study:
A number of 10 children were discontinuing the feet reflexology sessions more than four sessions and they were excluded from the statistical analysis.

Results
Table1: Characteristics of studied children with ASD.  1 showed the characteristics of children with autism.It was obvious from this table that the mean of children age was 6.75±3.23.Regarding their gender, the majority of children (76.6%) were male.In relation to mobility, 71.9% of them were independent.Table3 illustrated the severity of autism symptoms on pre-and post-intervention among children with ASD.It was obvious that there was a lessening in the severity of autism symptoms on post-intervention compared to preintervention (mild 43.3%, moderate 36.7% and severe 20%).Therefore, there were highly statistically significant differences between children regarding the severity of autism symptoms at 1% level of statistical significance.Table4: Severity of constipation on pre-and post-intervention among children with ASD.Table4 clarified the severity of constipation on pre and post-intervention among children with ASD.It was clear that children exhibited lower severity of constipation symptoms on post-intervention compared to preintervention (no constipation 16.67%, mild 53.33 % and moderate 16.67 %).In addition, the mean total score of constipation symptoms was lower on post-intervention compared to pre-intervention (35.93±16.04,40.23±17.51respectively).Therefore, there were highly statistically significant differences between children regarding the severity of constipation symptoms at 1% level of statistical significance.

Figure3: Pearson correlation between constipation and severity of autism symptoms on post-intervention.
Figure3 illustrated the Pearson correlation between constipation and severity of autism symptoms on postintervention.It showed that there was a significant correlation (R=0.858) at the 0.01 level of significance between constipation and the severity of autism symptoms on post-intervention.

Figure4: Pearson correlation between constipation and health/physical/behavior subdomain of ATEC on
post-intervention.Figure4 showed the Pearson correlation between constipation and health/physical/behavior subdomain of ATEC on post-intervention.It showed that there was a significant correlation (R=0.858) at the 0.01 level of significance between constipation and health/physical/behavior subdomain of ATEC on post-intervention.

Discussion
Owing to the various health problems that coexist with Autistic Spectrum Disorders, it presents challenges for children's health.One of the most common issues associated with autism is gastrointestinal problems particularly, constipation which results in further distress on children (Afzal et al., 2003;Ibrahim et al., 2009).Feet reflexology as a simple and useful procedure may provide satisfactory outcomes for constipation (Stephenson and Dalton, 2003).This study hypothesized that autistic children who would receive feet reflexology would exhibit improvement in autism symptoms and low constipation severity.
In this study, the majority of children were males; most of them drank 3-5 glasses/day and consumed 2 pieces of fruit/vegetable/day.A previous study (Newschaffer et al., 2007) which evaluated the epidemiology of autism spectrum disorders similarly, showed that autism is more prevalent among boys than girls.In addition, Mahapatra et al., (2018) found in their study "Longitudinal Epidemiological Study of Autism Subgroups Using ATEC Score" that 83% of children with autism were males.The children showed decreased consumption of fluid and fiber intake which predisposed them for another risk factor for constipation regardless of their mobility.
In relation to the hypothesis of the current study, the findings confirmed that autistic children who received reflexology sessions exhibited a significant improvement of constipation compared to pre-intervention.Improvement included stool frequency, consistency, and straining.These findings are congruent with those of Bishop (2003), who examined the effect of "reflexology in the management of encopresis and chronic constipation" in normal children with chronic constipation.She reported a significant increase in the stool frequency after six sessions of reflexology.In addition, increased appetite and improved sleep pattern.
In contrast, Lee et al. (2011) declined in their study any significant effects of reflexology as an intervention for patients with diverse diseases except for its effects on enuresis and did not recommend reflexology.Their point of view was based on the lack of studies and evidence of reflexology efficacy.Contradictorily, with the findings of the current study which asserted the positive effect of reflexology on constipation although the special characteristics of autistic children in addition to the probably inherited tendency of gastrointestinal issues with autism.
It is worth mentioning that during the search in the previous studies concerning the reflexology as an alternative intervention method for constipation in children, there was only one study done by Bishop.However, there were various studies confirmed the positive effects of reflexology on constipation.Guiling (2004) confirmed the benefits of feet reflexology in relieving and preventing constipation among elderly persons.In parallel with Woodward, Norton, and Barriball (2010), they reported the positive effect of reflexology sessions in relieving constipation in old women.A more recent study by Cevik and Zaybak (2018) entitled "The Effect of Reflexology on Constipation in the Elderly" concluded that feet reflexology is an effective nursing intervention achieved desirable positive changes in the symptoms of constipation.
Regarding autism symptoms, the results yielded that autistic child who received reflexology sessions had significantly lower mean scores of autism symptoms compared to pre-intervention.It included the total score of ATEC and the four subdomains (speech/communication, sociability, sensory/cognitive, health/physical/behavior). In addition, the severity of autism symptoms was significantly lowered.The researcher attributed these findings to the reported benefits of reflexology which include relieving pain, decrease sleep problems, eliminate toxins, regulate nerve functions, promote circulation, improve appetite, increase concentration and improve mood (Hodgson 2000 Furthermore, the current study revealed that there is a significant correlation between the severity of constipation and autism symptoms.In addition, Chaidez et al., (2014) found a correlation between gastrointestinal problems and maladaptive behavior in children with autism.In agreement, with the findings of Wang et al., (2011), they documented that the more severity of gastrointestinal problems, the more severity of autism symptoms Moreover, searching the literature for previous studies conducted on reflexology and its' effect on autism symptoms, the researcher did not find studies on this topic.Therefore, the current study considered the first.There is, however, frequent studies examined the effect of massage therapy on autism symptoms regardless of its type.Escalona et al., (2001) stated that following massage therapy, autistic children exhibited social relatedness behavior and fewer sleep problems, Lee et al. (2011) added that applying deep pressure massage can improve behavioral and cognitive symptoms of ASD.In addition, Walsh supposed that all children need tactile sensory stimulation.Therefore, the current study proved that foot reflexology has positive effects on autism symptoms and constipation in children with the autistic spectrum disorder.

Conclusion:
The study concluded that autistic children exposed to feet reflexology experienced lower mean scores of autism symptoms and less severity of constipation compared to pre reflexology massage.There was a significant correlation between constipation and the severity of autism symptoms.

Recommendation:
1. Feet reflexology should be integrated as a part of routine daily care for autistic children.
2. Courses that enable nurses to obtain a certification in reflexology are needed.
3. Further researcher on a wide range of sample to ensure the generalizability of the results.
the ATEC tool was confirmed by Cronbach's Alpha test (r = 0.91).Instrument Two: Constipation Assessment Questionnaire (CAQ).It adapted from Pediatric Constipation Assessment scale and Bristol Constipation Chart (BCC) (Woorely, et al., 2004) then modified by the researcher.It included two parts.Part one: It is a five-point Likert scale included 20 items to assess the presence and severity of constipation (stool frequency, consistency, straining, and painful passage).It ranged from almost never to almost always.The total score ranged from 0-100 points.Scoring system of CAQ: Daily habits assessment sheet to assess children mobility, fluid, fiber, and medication intakes.

Figure1:
Figure1: Distribution of fiber intake among children with ASD.Figure1 represented the distribution of fiber intake among children with ASD.It clarified that the majority of children (83.33%) consumed 2 pieces of fruit/vegetable/day.
/day 3-5 glasses/day 6-8 glasses/day ≥ 9 glasses/day Table2: Mean and standard deviation of autism symptoms on pre-and post-intervention among children with ; Center for Spirituality & Healing and Charlson Meadows, 2015).Consequently, functions of neurologic and digestive systems improved which are closely linked to frequent symptoms associated with autistic children.In other words, regulating the internal systems is reflected with improved communication, sociability, cognitive, physical and behavioral skills.This point of view is supported by the findings of Adams et al., (2011) who mentioned in his study that children with gastrointestinal symptoms exhibit serious behaviors.

Table3: Severity of autism symptoms on pre and post-intervention among children with ASD.
Highly statistical significant at P˂0.001.Table2 represented Mean and standard deviation of autism symptoms on pre-intervention and after 6 weeks of feet reflexology.As illustrated in the table, the children had lower mean scores of autism symptoms on postintervention compared to pre-intervention speech/communication, sociability, sensory/cognitive, health/physical/behavior subdomains and the total score (19.50±3.39,9.20±3.23,11.96±5.38,20.50±5.63 and 61.07±16.44respectively).Therefore, there were highly statistically significant differences between children autism symptoms at 1% level of statistical significance.