|Year : 2019 | Volume
| Issue : 1 | Page : 3-16
Yoga as a therapeutic tool in autism: A detailed review
Soccalingam Artchoudane1, Ananda Balayogi Bhavanani2, Meena Ramanathan2, Artchoudane Mariangela1
1 Center for Yogic Sciences, Aarupadai Veedu Medical College and Hospital, Vinayaka Mission's Research Foundation, Puducherry, India
2 Centre for Yoga Therapy, Education and Research, Sri Balaji Vidyapeeth, Puducherry, India
|Date of Web Publication||13-Jun-2019|
Ananda Balayogi Bhavanani
entre for Yoga Therapy, Education and Research, Sri Balaji Vidyapeeth, Pillayarkuppam, Puducherry - 607 402
Source of Support: None, Conflict of Interest: None
Autism is a complex neurodevelopmental disorder affecting systems of the body and behavior. Its growth rate is approximately 3% in children. This review was undertaken to search and critically analyze the literature about musculoskeletal, cardiovascular and neurological function, and behavioral outcomes of yoga interventions for individuals with autism spectrum disorder. This systematic review has four-stage screening process and rigorous critical appraisal, which resulted in the inclusion of 36 studies. As a result, in children with autism spectrum disorder with (i) the presence of muscle weakness: yoga may decrease sympathetic activity and autonomic arousal and thereby improve handgrip strength (HGS); (ii) lowered cardiac vagal tone and elevated sympathetic tone, resulting in autonomic abnormalities including impaired language, attention, and cognition: yoga reduces blood pressure and improves attention without sympathetic activation; (iii) slower reaction times and greater standard deviations: Pranayama practice enhances central processing ability; and (iv) sensory processing issues with behavior regulations give rise to the presence of repetitive behaviors: yoga improves sensory integration, motor imitations, communications, and their own thoughts and behaviors related to physical, social, and emotional well-being. Hence, this review of clinical studies suggests that approach built on yoga intervention is worth pursuing. Desired outcomes include reduction of autism rate and improved quality of life.
Keywords: Cognitive function, musculoskeletal function, neurological development, quality of life, yoga therapy
|How to cite this article:|
Artchoudane S, Bhavanani AB, Ramanathan M, Mariangela A. Yoga as a therapeutic tool in autism: A detailed review. Yoga Mimamsa 2019;51:3-16
|How to cite this URL:|
Artchoudane S, Bhavanani AB, Ramanathan M, Mariangela A. Yoga as a therapeutic tool in autism: A detailed review. Yoga Mimamsa [serial online] 2019 [cited 2022 Dec 1];51:3-16. Available from: https://www.ym-kdham.in/text.asp?2019/51/1/3/260361
| Introduction|| |
Autism spectrum disorder (ASD) is a neurodevelopmental disorder affecting an average of one in 37 children, and these conditions led to increase in the estimates from 13.6% to 16.8% (Suresh, 2018; Arora et al., 2018; Baio et al., 2018). The awareness and diagnosis of ASD, along with the limitations of current therapies, has necessitated more research for better treatments to improve lifelong outcomes and the dissemination of educational programs to the autism community. In the past decade, many researchers have investigated the effects of yoga on markers of impairment of social interaction/communication, stereotyped behavior, and sensory dysfunction.
To review the efficacy of yoga on the following functions and behaviors among individuals with ASD:
- Musculoskeletal function
- Cardiovascular function
- Neurological function
To review the role of yoga through the following parameters among children with ASD:.
- Musculoskeletal function : Handgrip strength
- Cardiovascular function : Heart rate and blood pressure (BP)
- Neurological function : Reaction time
- Behaviors : Sensory processing, motor execution, social interaction, communication, and cognition.
| Yoga as Intervention on Existing Studies in Autism Population|| |
We searched literature systematically to locate studies on yoga that reported handgrip strength, BP, reaction time, and quality of life (QoL) data of individuals with ASD. The search was limited to published articles in English between 1991 and 2018. Publications were identified using electronic searches; major databases, including Web of Science, PMC, and PubMed were searched using these keywords: yoga, yoga therapy, handgrip strength, blood pressure, reaction time, autism, autistic disorder, Asperger's disorder, Asperger syndrome; pervasive developmental disorder; autism spectrum disorder (ASD); and quality of life.
The literature search yielded a total of 36 articles potentially relevant to this review [Table 1]. To be included in this review, the study must include yoga, handgrip strength, BP, reaction time, QoL, or behavior of participants with ASD. The first and second authors screened 18 articles to identify the studies that met the criteria of inclusion for this review [Table 2]. A point-by-point method ([agreements/(agreements + disagreements)] × 100) was used to calculate the reliability for identifying studies that met criteria, and the reliability was found to be 100%. A review identified 124 such studies; only one study examined the impact of yoga/dance intervention that yoga improved socioemotional and behavioral changes with a significant improvement in attention and cognition (Bremer, Crozier & Lloyd, 2016; Rosenblatt et al., 2011). Weaver (2015) reviewed 23 such studies; only one study (Koenig, Buckley-Reen & Garg, 2012) examined the effects of daily yoga program that improved maladaptive behaviors in children with ASD. The analysis of improvement in individuals with ASD showed that yoga improved socioemotional behavior, attention, cognition, maladaptive behaviors, balance control, concentration, planning and execution times, depth perception, executive functioning, stress and lowered pulse rate, and also global self-worth and perceptions of physical well-being in high-functioning ASD (HFASD). Yoga not only benefits individuals with ASD but also all developmental disorders as we found improved IQ ratings, social adaptation, self-confidence, communication, and learning disabilities in typically developed children.
|Table 1: A summary of published clinical trials examining yoga intervention and relevant outcomes in individuals with ASD|
Click here to view
|Table 2: A summary of published clinical trials examining relevant durations of yoga intervention in individuals with ASD|
Click here to view
Berger, Johnson-Silver & Stein (2009) found that yoga program reduces negative behavior scores and increases balance control, whereas in children with HFASD, no improvement was observed in global self-worth and perceptions of physical well-being. Peck, Kehle, Bray & Theodore (2005) assessed that yoga improved attention and concentration in children. Manjunath & Telles (2001) demonstrated that yoga improved planning and execution times and Raghuraj & Telles (2003) added a significant improvement in depth perception. These studies have promoted that yoga has positive effects on executive functioning and depth perception. Goldberg (2004) studied that relaxation-based yoga program reduced stress and lowered pulse rate in children with autism.
Michelle, Serwacki & Catherine (2012) reviewed the impacts of yoga on atypically developed children. The results included (i) decreased level of stress and significant reductions in pulse rate in children with autism; (ii) elevated IQ ratings and social adaptation scores in children with intellectual disabilities; (iii) greater self-confidence, social confidence and communication in children with emotional, behavioral, and learning problems; (iv) improved attention and concentration in children with learning disabilities.
Impaired musculoskeletal function
Kern et al. (2013) examined that children with ASD have significantly poorer handgrip strength as compared with neurotypical children. The evidence has shown musculoskeletal dysfunction or poor function that affects muscle tone, gross motor function and posture, balance, gait pattern, and neuromuscular coordination as found in twisting a bottle cap. Handgrip dynamometer is a valid tool for measuring overall muscle strength and suggests that children with ASD have muscle weakness as given in [Table 1]. If such physical impairments include fine and gross motor problems (Provost, Heimerl & Lopez, 2007), movement/motor skill deficits (Green et al., 2009), dysfunctional posture and muscle tone (Jong, Punt, Groot, Minderaa & Hadders, 2011), hypotonia (Ming, Brimacombe & Wagner, 2007), balance problems (Minshew, Sung, Jones & Furman, 2004), and gait pattern differences (Calhoun, Longworth & Chester, 2011) reflect the issue of general physical condition in muscle weakness of children with ASD. Hardan, Kilpatrick, Keshavan & Minshew (2003) added that handgrip strength was significantly weaker in children with ASD. Bhat, Landa & Galloway (2011) stated that one of the earliest motor signs of an ASD may be weakness in pronation and supination as in turning a doorknob or twisting a bottle cap and also added that abnormal muscle tone in children with ASD may play a role in the limitations of activities of daily living. Anecdotal reports and limited research suggest that children with ASD are weaker in muscle strength. Thus, the functional effects of muscle weakness in children with ASD could be widespread.
Role of yoga in musculoskeletal function
There are few studies which show that yoga helps in improving musculoskeletal function. Dinesh et al. (2014) studied that pranayama improved handgrip strength and handgrip endurance by decreased autonomic arousal in healthy volunteers. Mandanmohan, Lakshmi, Kaviraja & Ananda (2003) demonstrated that yoga practices improve lung function, strength of inspiratory and expiratory muscles, as well as skeletal muscle strength and endurance. Bhavanani, Udupa, Madanmohan T & Ravindra (2011) reported that both fast and slow Surya Namaskar increase isometric handgrip strength and handgrip endurance. It is suggested that yoga can be introduced to autism population to improve muscle strength and overall health.
Impaired cardiovascular function
The perceived cardiovascular factors in children with autism are lowered cardiac vagal tone and no standard stimulus strengths. This factor influences autonomic response that leads to social, emotional, and cognitive dysfunction. Giblin, de Leon, Smith, Sztynda & Lal (2013) identified autonomic activity as a predictive tool for cognitive decline and reported that higher sympathetic drive may benefit calculation and memory skills while being detrimental to judgment, comprehension, orientation, attention and language ability. Rushmer (1972) analyzed that the stimulation of arterial baroreceptors at every heartbeat is enough with above 45 mmHg of mean arterial pressure, ejection pressures of the heart. Changes in arterial pressure induce the changes in cardiac cycle intervals (Julu, Kerr, Hansen, Apartopoulos & Jamal, 1997), so in autism the cardiac vagal tone is low, and Keele, Neil & Joels, 1982; Guyenet et al., 1996; and Jordan (1995) reported that cardiac vagal tone (amount of vagal efferent activity to the heart) relies on the degree of stimulation to arterial baroreceptors.
Role of yoga in cardiovascular function
Ming et al. (2005) incited against the statement of provoked autonomic responses to socioemotional stimuli (Hirstein, Iversen & Ramachandran, 2001; Palkovitz & Wiesenfeld, 1980). According to Ming et al. (2015), it requires standard stimulus strengths, which are difficult in children with ASD because of their uncooperativeness. Several evidences suggested that yoga increases parasympathetic nervous system (PNS) and gamma-aminobutyric acid (GABA) activity, which leads to improvement in cardiac function (Streeter, Gerbarg, Saper, Ciraulo & Brown, 2012).
Impaired neurological function
Several studies on histopathological, structural imaging, and head circumference in autistic children have shown increased brain volume; neuronal growth dysregulation; and associated abnormalities in specific neural sites of cerebellum, medial temporal lobe, and frontal lobe. Helen (2006) & Waldie & Saunders (2014) added neurological impairments related to deficits in interpersonal interaction such as problems remembering and identifying people; the inability to perceive social cues; and misunderstanding nonverbal cues such as gestures, facial expressions, and speech prosody as seen in children with ASD. The problem in the frontal cortex and the circuits leading to and from the frontal lobe is associated with neural level of executive functions. This includes planning, attention, social reciprocity, working memory, problem-solving, task switching, verbal reasoning, mental flexibility, monitoring of actions, and inhibitory control. Inhibitory control allows tolerating dominant responses or ignoring distracting stimuli in order to give an appropriate response, whereas in autism it inhibits or stops performing an appropriate action that leads to social inappropriate behavior, sometimes extreme emotional outburst (Waldie & Saunders, 2014). However, to avoid these characteristics in autism, where the inhibitory circuitry is underactivated (Kana, Keller, Minshew & Just, 2007), the inhibitory control requires neuronal synchronization of frontal lobe (anterior cingulate gyrus and middle cingulate gyrus) and posterior areas of the brain such as the striatum, basal ganglia, and the insula.
Kana et al., 2007; Cherkassky, Kana, Keller & Just, 2006; and Murias, Webb, Greenson & Dawson, (2007) found that cortical connectivity between frontal and posterior regions have been abnormal resting state in individuals with autism. Children with ASD have social difficulties involving eye contact, reciprocal interactions, and responding to emotional cues. Dawson et al. (2002) suggested that the ventromedial prefrontal cortex and the medial temporal lobe make up a brain system specialized for social processing that is deficient in autism, impairing facial processing ability, reducing attention to faces, and leading to difficulties with theory of mind, language, and social skills.
Role of yoga in neurological function
Yoga therapy may help in inherently building the ability to exchange information to and fro through all senses that make a meaningful response, integrating senses in central nervous system and enabling function of attention, emotion, cognition, coordination, arousal levels, and autonomous system (Betts & Betts, 2006; Khalsa, Amen, Hanks, Money & Newberg, 1999; Segal et al., 2010; Orme-Johnson, 2006; Orme-Johnson, Schneider, Son, Nidich & Cho, 2006; Zeidan et al., 2011; Newberg, Wintering, Khalsa, Roggenkamp & Waldman, 2010).
Review of study on behavior
Based on the published studies reviewed here [Table 1], there are neither proper study design, standardized intervention protocols, nor outcome measures to assess the effect of yoga therapy in children with ASD. The current evidence-based studies do not provide a complete methodology as to guide duration, frequency, intensity, group size, or age range of children with ASD (Gwynette et al., 2015; Payakachat, Tilford, Kovacs & Karen, 2012). Furthermore, the evidence of study review is not clear about the value of parent and/or teacher involvement. We assessed the strength of evidence using study-quality assessment including study design, diagnostic approach, participant ascertainment and characterization, intervention description, outcomes measurement, and statistical analysis. We assert limited evidence in autism, but when considering yoga intervention held to evidence-based standards, there is ineffective matter and really nothing at all (Stephen & Robert, 2015; Singer & Ramita, 2015).
Important behavioral characteristics of Autism
- Sensory processing dysfunction
- Emotional response
- Visual response
- Listening response
- Sensory issues to taste, touch and smell
- Motor execution deficits
- Gross motor skills
- Fine motor skills.
- Communication disorders
- Verbal and nonverbal communication
- Receptive language
- Expressive language.
- Body use
- Object use
- Restricted interest.
- Social interaction
- Activities of daily
Sensory process dysfunction
The analysis of sensory process dysfunction caused impaired behavior such as inability to react, rocking, repetitive stereotyped behavior, overreactivity, lack of responsiveness, social interaction, self-injurious, aggression, attention, communication, and self-stimulatory behavior. Huebner (2001) & Schaaf & Miller (2005) reported that children with ASD have behavioral issues because of poor sensory process and inability to react. Mayes & Calhoun (1999) suggested the symptoms of autistic children including problems with somatosensory disturbance (i.e., frequently engaging in movement or rocking), perseveration (i.e., repetitive stereotypical movements), mood disturbances (e.g., overreactivity and lack of responsiveness), social interaction, atypical developmental patterns, and problems with attention and safety. Brian, Matthew, Tia, Grace & James (2009) suggested executive dysfunction in children with HFA that restricted, repetitive behaviors and sensory processes are not in line of shared neurocognitive mechanism. Watling, Deitz, Kanny & McLaughlin (1999) found the limitations of functional behavior due to dysfunction in sensory process and perception as well in neurological and communication. Roberts, King-Thomas & Boccia (2007) reported that sensory processing dysfunction is common in children with ASD (Schaaf & Nightlinger, 2007; Smith, Press, Koenig & Kinnealey, 2005). Baranek (2002) & Tomchek & Dunn (2007) suggested that poor sensory integration causes sensory stimuli overload or reactions and impairments in attention and arousal. In autism, several studies have reported that the growth of brain gets arrested and decelerated, that is, thinning of the cortex area which involved auditory, visual and cognitive performance, and formation of emotional memory (Hughes, 2007; Wallace, Dankner, Kenworthy, Giedd & Martin, 2010; Bauman & Kemper, 2005; Baron-Cohen et al., 2000; Markramand & Markram, 2010). Empathy is also one of the sensory processes where emotional response begins with the recognition of another person's mental and emotional existence. According to 'theory of mind' and amygdale theory of autism, the amygdale of children with ASD is not activated when making mentalistic inferences from the eyes, whilst people without autism showed amygdala activity (Baron-Cohen, Leslie & Frith, 1985; Baron-Cohen, Ring & Bullmore, 2000; Iacoboni & Dapretto, 2006). In essence, autistic children are unable to understand their own emotions and as a result emotions of others. However, sensory stimuli overload or reactions may be extremely disruptive that cause self-stimulatory behavior (Bachman & Sluyter, 1988; Watters & Watters, 1980). Andrea et al. found that self-aggressive behaviors are much less frequent than those heteroaggressive behaviors among HFASD and LFASD, and self-injury was more frequent in self-aggressive than heteroaggressive children in both verbal and nonverbal groups (Andrea et al., 2016; Rojahn, Matson, Lott, Esbensen & Smalls, 2001).
Case-Smith & Bryan, 1999; Dawson & Watling, 2000; Linderman & Stewart, 1999; and Watling & Dietz (2007) reported that impaired behaviors, stereotypic motor movements, self-injurious behaviors, and aggression have been correlated with these sensory processing abnormalities. Children with ASD mostly have behavior problems arising from poor integration of sensory input and show evidence of sensory integration dysfunction through variable activity levels, difficulty calming after physical activity, difficulty with attention and regulation, sensory defensiveness, lack of variety in play activities, clumsiness, excessive seeking of sensory input, or excessive trepidation around seemingly innocuous physical tasks such as climbing stairs (Kenny, 2002).
Origin and ineffectiveness of sensory integration therapy theory
Sensory integration therapy (SIT) model may interfere with neurological processing and integrate sensory information that disrupted the construction of purposeful behaviors (Schaaf & Miller, 2005; Watling & Dietz, 2007). Koenig, Pfeiffer, Moya, Megan & Lorrie (2011) reported that the effect of Ayres' sensory integration treatment in children with ASD were lack of fidelity measures and limited by the types of designs ensuring validity of the SIT provided. Miller, Schoen, James & Schaaf (2007) ascertained the ineffectiveness of SIT due to type II errors and several challenges in the designs. The effect of intervention depended on design that interferes with each behavior of child's ability to engage in or learn.
Role of yoga as sensory integrating process
Allen & Anita (2014) found that yoga improved sensory process and acted as alternative therapy for children with ASD. Betts & Betts (2006) mentioned that yoga as a natural form of SIT helped attain more focus and concentration, build emotional and social skills, and enhance physical balance and flexibility in children with ASD. Veague (2010) supported that SIT for autistic children with sensory dysfunction helped in the reduction of negative behaviors. SIT was used for children with ASD, developmental and learning disorders, and attention-deficit disorder (Wilbarger & Wilbarger, 1991; Polenick & Flora, 2012). Koenig et al. (2012) studied the effectiveness of yoga in sensory integration on autistic children that resulted in significant positive changes.
Celiberti, Heather, Kimberly, Sandra & Jan (1997) and Kern, Koegel & Dunlap (1984) observed the effect of antecedent exercise on high rates of physical self-stimulatory behavior: walking had little influence and jogging had sequential impact in individuals with autism. On contrary, Larson & Miltenberger (1992) noted no change in behavior problems after 15 min of antecedent jogging whereas other researchers (Bachman & Sluyter, 1988) reported that antecedent jogging improved all three disruptive behaviors such as inappropriate vocalizations, repetitive movements, and off-task behaviors. However, yogasana practices are the physical postural movements along with breath awareness that facilitates the development of body awareness, concentration, and memory and provides vital skills for children with a developmental disability (Ramanathan & Bhavanani, 2017).
Yoga practice that includes movement, breathing, and chanting is likely to present itself as challenging to these children and individuals (Khalsa, 2010). Sequeira & Ahmed (2012) have suggested that yoga practice harmonizes both their emotional and physical well-being as they move from childhood into adult life. Thus, it is evidence-based holistic solution for clinical studies and neuroscience research that would reach desired outcomes including relief of clinical symptoms of the disease, facilitated expression of feelings and skills, greater relaxation, as well as improved family and social QoL. Research on yoga therapy for autism must explore noninvasive techniques that facilitate self awareness and develop empathy towards others. This research emphasizes the therapeutic potential of yoga, ability to protect and improve neurological response, as well as solid research record exists in other neurological conditions (Khalsa et al., 1999; Segal et al., 2010; Orme-Johnson, 2006; Zeidan et al., 2011; Newberg et al., 2010). Gulati, Loganathan, Mooventhan, Lahiri & Telles (2018) suggested that longer intervention time would result in positive changes including health, sensory, communication, sociability, and sensory assessment checklist scores and reported that even 2 weeks of yoga therapy improved behavior, aggression, and calmness in children with ASD.
Impaired motor execution
The qualitative and quantitative evaluation of gross, fine, and oral motor dysfunction suggested that neuromotor impairments are the symptoms of communication and social interactions in children with ASD (Leary & Hill, 1996; Noterdaeme, Mildenberger, Minow & Amorosa, 2002). Belmonte et al. (2013) stated that oral motor movements involved the tongue and lips and speech fluency in children with autism (Amato & Slavin, 1998). Thus, the vocal and degree speech fluency and other motor imitation skills are relatively intact with cognitive skills (Thurm, Lord, Lee & Newschaffer, 2007). Sensory stimulus overload caused disruptive cognitive networks and inability to respond effectively to stimulation in such condition it initiates social behaviors such as heightened social fears, anxieties, and internal conflicts, toward family, friends, and peers (Sequeira & Ahmed, 2012). Gillberg (2010) also suggested that motor impairment encompasses cognitive, affective, and motor coordination.
Role of yoga in motor execution
This review found that yoga practice for longer time may slow down motor, facial, vocal, and auditory cues that impact cognitive performance and motor imitation skills of children with ASD and also help in integrating process of visual–motion (Radhakrishna, Nagarathna & Nagendra, 2010; Gepner & Feron, 2009; Gepner & Mestre, 2002).
In autistic children, there are some challenges with communication abilities that affect understanding and expression of both verbal and nonverbal communication behaviors, and the degree of difficulty in each of receptive and expressive communication areas differs greatly among individuals. Boddaert & Zilbovicius (2002) reported that bilateral hypoperfusion of temporal lobe can be related to language deficits or avoidance of verbal mediation-detected maladaptive behavior in individuals with autism. Bavin et al. (2014) found that severity of ASD was related to inefficient lexical processing, which may complicate the development process of the ability to integrate auditory and contextual information. The delayed developmental processes appeared to be the form of impaired or delayed language abilities at a very early age (Luyster, Kadlec, Carter & Tager-Flusberg, 2008; Mitchell et al., 2006).
The receptive language disorder occurs as a result of pervasive developmental disorder or damage to brain by trauma, tumor, or disease (“Receptive Language Disorder”, 2019). Receptive language disorder may also be related to difficulties with attention and concentration. Thus, the behavior, literacy, social skills, sensory processing, executive functioning, planning and sequence, auditory processing, or language comprehension can be severely impaired (Waterhouse & Fein, 1982).
Association of receptive language disorder with expressive language disorder includes frequently grasping for right words, using wrong words in speech, making grammatical mistakes, and inability to start or hold a conversation (“Receptive Language Disorder”, 2019). However, verbal communication in children with ASD may be difficult and illegible, whilst nonverbal communication is generally known to be in the form of aggression, passivity, self-abusive behavior, or echolalia. Happe & Frith (1996) found that absence of communication may be ineffectiveness of social interaction and itself as expressive language impairment.
Role of yoga in communication
Radhakrishna et al. (2010) found that yoga therapy improved communication, language, play, and joint attention in individuals with ASD. Lee (2019) added that yoga yielded an increase in communication skill.
This review found impairments in cognition and clinical symptoms due to homeostatic imbalance across the central nervous system and PNS among inhibitory, feedback, and feedforward loops (Thayer & Brosschot, 2005; Thayer, Hansen, Saus-Rose & Johnsen, 2009).
Role of yoga in cognition
In children with ASD, both central and peripheral nervous system does not function properly and yoga therapy steers both top-down and bottom-up of these deficits (Streeter et al., 2012). Chan, Sophia, Siu, Lau & Cheung (2013) examined that Chan-based mind–body exercise had a positive effect in enhancing the self-control of children with ASDs. They found that cognitive enhancement in children with ASD improved brain functioning, elevated brain activity and also helped restore self-regulatory mechanisms including self-stimulatory and repetitive behaviors as well as attention and emotion regulation.
This review examined that mind–body intervention even for 1 month had had positive results and increased ability to change their own thoughts and behaviors to enhance their mental and physical health (Chan et al., 2013). More scientific studies (Hourston & Atchley, 2017) have examined therapeutic effects of yoga contribution to mind–body interventions on insomnia (Sarris & Byrne, 2011), chronic pain (Wahbeth, Elsas & Oken, 2008), cardiovascular problems (Yeh, Wang, Wayne & Phillips, 2008), anxiety (Chen et al., 2012), and depression (Agnes et al., 2012).
Impaired social interaction
Social behavior addresses individual imbalance or inadequacy in repeated brain stimulation to put into effect and development that support relationships, character, decision-making, and skills for well-being (Moffitt et al., 2011). However the result of imbalanced neurological response to cues from external world, is a stress that the child experiences, signifying complex emotional and cognitive functions. The brain should be protected from unhealthy sensory overload (Begley, 2011); otherwise, lack of brain response or activity affects stress mechanism that reflects through basic behaviors such as impaired social interactions, eye contact, facial expression, imitations, learning, and inability to explain the feeling of empathy toward other beings (Dinstein et al., 2011; “American Psychiatric Association”, 2000).
Role of education in social interaction
We reviewed the evidence-based applied education for individuals with ASD: the teacher (1) must know discipline and content knowledge, curricular knowledge, pedagogical knowledge, and knowledge of self and culture (McArdle, 2010); (2) include interactive, multidimensional, and experiential activities (Lieberman & Pointer, 2008); (3) follow the purpose, visibility of learning, shared sense of the whole task, or goal of education (McArdle, 2010); and (4) can add instructional practices that are specified to suit individual strengths and challenges of individuals (Lynch & Irvine, 2009). Eric examined specialized education for children with ASD; effective teacher education and training program indicate better and more focused comprehensive program (Eric, 2012). Though there have been varied educational and behavioral interventions, there is still a lack of target specific treatment, in autism related core and co-morbid symptoms. Koyeli et al. suggested that the interventions given should be based on evidence and result oriented outcomes (Koyeli, Leera & Vibha, 2015). Stahmer, Schreibmanb & Cunningham (2011) analyzed motor imitation skills including poor motor imitation and good motor imitation and reported that there is no effective intervention for children with ASD (Lonigan, Elbert & Johnson, 1998). Tissot & Evans (2003) found that traditional teaching methods for visual learners also failed to communicate or understand language among children with ASD.
Impact on quality of life
In this review, the effectiveness of health-related QoL of autistic individual is evaluated through physical health, psychosocial health, and social functioning, and these psychometric measures will be effective for future studies. Ikeda et al. suggested that Pediatric Quality of Life Inventory (PedsQL) is an appropriate tool for QoL measures in individuals with ASD and self-reported measures are likely to be more accurate (Ikeda, Hinckson & Krageloh, 2014). Johnny & Julie (2011) examined the benefit and side effect of psychotropic drug, and the result was not well cleared. Natasha, Heather, Fellana, Zhang & John (2014) analyzed that risperidone may have beneficial effect on aggression and not accompanied by reduction in core ASD symptoms, but its common adverse effect is somnolence (Gahan, Cynthia, Eriene, Zhu & Fiona, 2007). Christopher et al. (2013) found that neuroleptics and antidepressant drugs may help lower IQ or LFASD and stimulant useful for HFASD. This review found that no treatment completely ameliorates the symptoms of ASD or works for all children with the disorder. The developmental nature of the disorder and heterogeneity makes it a necessity for one specific treatment best for children with ASD. Hence, this review includes research studies done with intervention techniques addressing characteristics associated with different outcomes in the provided treatment.
There are questionnaires to assess QoL measures in autistic children such as (1) general measures of behavior using Aberrant Behavior Checklist (ABC), Child Behavior Checklist, Vineland Adaptive Behavior Scales, Social Responsiveness Scale, Repetitive Behavior Scale-revised, (2) cognitive measures oriented to behavior included Stanford–Binet Intelligence Scales (5th Edition), Mullen Scales, Bayley Scales, and Wechsler Intelligence Scales; and (3) clinical and behavioral treatment using medications such as atomoxetine, risperidone, lamotrigine, and methylphenidate on ADI-R, ADOS, and cognitive measures (Payakachat et al., 2012). The outcome measurements can be used for health services and clinical and cost-effectiveness applications. Children with ASD differ in age and type of onset; severity and comprehensiveness of symptoms include impairments of communication, restricted interest and stereotyped behavior, and extent of language delay and intellectual disability (Sacrey, Germani, Bryson & Zwaigenbaum, 2014; Lord & Bishop, 2010).
We reviewed health-related QoL of children with ASD that covered the limitations of clinical measures such as (1) PedsQL offers four categories of age group for parent proxy-report and three categories of age group for child self-report and has multidimensional scales of physical, emotional, social, and school functioning along with three summary scores of physical health summary, psychosocial health summary, and total score. PedsQL has good properties of psychometric measures among healthy populations as well as children with chronic conditions (Varni, Burwinkle, Seid & Skarr, 2003). Limbers, Ripperger-Suhler, Heffer & Varni (2011) demonstrated psychometric measures of PedsQL and its feasibility, reliability, and validity among children with psychiatric disorders.
Ravens-Sieberer et al. (2007) demonstrated the instrument Kidscreen-27's psychometric properties that deals with 8–18-year-old children's burden or disability of particular diseases, especially (1) physical well-being including physical activity, energy, and fitness; (2) psychological well-being including positive emotions, satisfaction with life, and feeling emotionally balanced; (3) autonomy and parents including relationships with parents, the atmosphere at home, feelings of having enough age-appropriate freedom, and degree of satisfaction with financial resources; (4) peers and social support including relationships with other children/adolescents; and (5) school environment including perceptions of cognitive capacity, learning and concentration, and feelings about school.
The Child Health Questionnaire (CHQ-PF28 and CHQ-CF87) has feasibility and good psychometric properties including physical functioning, emotional/behavior role functioning, physical role functioning, mental health, bodily pain, general behavior, self-esteem, general health perceptions, parental impact (emotional), parental impact (time), family activities, family cohesion, and change in health (Raat, Botterweck, Landgraf, Hoogeveen & Essink, 2005; Raat, Landgraf, Bonsel, Gemke & Essink, 2002). Jones, Guildea, Stewart & Cartlidge (2002) evaluated the impact of child's health problem using health status questionnaire on clinical measures including neuromotor function (sitting, walking, hand use, and head control), seizure, hearing, communication, vision, cognitive, malformation, and other physical disability (growth, respiratory, gastrointestinal, and renal). Child Health and Illness Profile (CHIP-CE and CHIP-AE) reliably and validly assesses the health status of children and adolescent population (Riley et al., 1998; Riley et al., 2004). Functional status (FS II-R) instrument can find the difficulties in child's functioning including communication, mobility, mood, energy, sleep, play, eating, and toileting patterns that are present in child's health condition (Stein & Jessop, 1990). Grosse, Prosser, Asakawa & Feeny (2010) analyzed all the available generic instruments for quantifying health outcomes, and a number of methodological problems encountered while being applied for panel's recommendation to children. Baron-Cohen (2001), Tilford (2002), & Petrou (2003) found compounded issues of instrument, that is, insufficient scale to measure the intellectual ability, reading comprehension, and communicative level of children with ASD.
Some more HRQoL instruments that are relevant to ASD symptoms are as follows:
- Quality well-being – Three functioning scales: Mobility, physical activity, and social activity. Some questions (hangover and sexuality) are not relevant for children and researchers considered leaving out these items (Seiber, Groessl, Ganiats & Kaplan, 2008)
- Assessment of QoL (AQoL-6D) – Independent living, social and family, mental health, coping, pain, and senses. Preference-weighted scores specifically for adolescent community (Moodie, Richardson, Rankin, Iezzi & Sinha, 2010)
- EuroQol 5-dimension (EQ-5D) – Five questions on mobility, self-care, usual activities, pain/discomfort, and anxiety/depression on current health status. Instrument is appropriate for children aged 8 years and above (Ravens-Sieberer et al., 2010)
- Health Utilities Index (HUI) – HUI2: Sensation, mobility, emotion, cognition, self-care, pain, and fertility; HUI3: Vision, hearing, speech, ambulation, dexterity, emotion (irritability, anxiety, night terrors, and anger), cognition (i.e., learning ability), self-care (i.e., eats, bathes, dresses, and uses the toilet independently), and pain. Both instruments allow negative preference-weighted scores, worse than dead (Horsman, Furlong, Feeny & Torrance, 2003)
- Child Health Utility (CHU 9D) – Worried, sad, pain, tired, annoyed, schoolwork, sleep, daily routine, and activities on current health status (Stevens, 2009)
- Communication DEALL Developmental Checklist (CDDC) – There are eight domains including gross motor, fine motor, activities of daily living, receptive language, expressive language, social, cognition, and emotional on current health status. Instrument is precise to symptoms of children with ASD and developmental on month having five responses of 36 questionnaires on each domain (Karanth, 2007).
A few studies are about cost-effectiveness of treatment services for children with ASD and associated heterogeneity in intellectual disability (Brouwer, van Exel, Koopmanschap & Rutten, 1999). Most of the instruments were developed without consideration for use in autistic children, with the exception of the CDDC.
There is limited information that several domains included in HRQoL instruments are actually sensitive to behavior problems and correlated with musculoskeletal, cardiovascular, and neurological function in children with ASD.
Rationale to treat
Mind–body-based treatments may be too limited for timely access. This point is undoubtedly true, but yoga therapy has not yet been used specifically targeting core and comorbid symptoms in individuals diagnosed with ASD.
Certainly, many intervention-based educational methods might also be considered as an interim treatment. However, increasing the availability of the most effective intervention is another strategy. Researchers have found no strong evidence that ASD has musculoskeletal, cardiovascular, and neurological function and QoL involvement, which are the primary mechanism for the action of yoga therapy (Manjunath & Telles, 2001; Ming, Peter, Michael, Susan & Mary, 2005; Kern et al., 2013; Herrero et al., 2015). Stephen & Robert (2015) found side effects of drugs risperidone and aripiprazole for the treatment of autism that gain weight and sedation. Johnny & Julie (2011); Natasha, Heather, Fellana, Zhang & John (2014); Christopher et al. (2013) reported that pharmacologic agents failed to respond in ASD whereas yoga played a vital role increasing GABA activity and vagal tone (Nemeroff et al., 2006). Therefore, there is no evidence for effective mechanism, but as noted previously, it is available in scientific literature that yoga may be an effective treatment in a non-ASD population for conditions that are commonly comorbid with ASD (Gwynette et al., 2015). Future studies should consider yoga intervention and outcome measures aimed at system of musculoskeletal, cardiovascular, and neurological function and QoL through core ASD symptoms and commonly comorbid conditions, reflecting the clinical needs of patients. Thus, this review includes both human system and behavioral aspects of the individual with ASD.
| Discussion|| |
There has been a rapid rise in the reported prevalence of ASD in the last decade. The increased prevalence of children with ASD increased the demand for services and associated costs in both educational setting and medical treatment. Different treatments could prevent the symptoms of autism or lead to complete recovery of affected children.
Specific measures of children with ASD are obtained by clinical observation and must be correlated with child or parent-reported HRQL measures from clinical trials. Health care and educational systems have failed to develop independent living skills of children with ASD. Most of the various hypotheses studied stand to support and enhance the medical and behavioral therapy, but this has proved as gross failure, inefficient, and requires reform. Yoga therapy has the potential to address target-specific issues. Different systems of care that provide improved outcomes for children with ASD must rely on clinical trials. This review provides a correlation between sensory integration and improved behaviors.
The extracted articles were analyzed for therapeutic potential related to various aspects of musculoskeletal, cardiovascular, and neurological function and behavioral intervention such as sensory processing, motor execution, communication, cognition, and social interactions in ASD. Most of the intervention models for ASD are based on target-specific deficits associated with the disorder and include various theoretical orientations. In such settings, yoga therapy can play a vital role in various systems of individuals with ASD and maladaptive behaviors.
Yoga intervention needs to pay more attention in the scientific and methodological aspects as a potential intervention to treat and relieve symptoms of autism. The view that yoga therapy is a tool to treat chronic neurodevelopmental disorder is not confirmed by evidence-based research. Thus, it has been shown that various models of yoga practices have been beneficial adjunct therapies in activities of daily living, social relationships, and interpersonal interactions. Sequeira et al. reviewed that yoga performance is associated with changes of brain tissues in short- and long-term state and suggesting the formation of new synapses, resulting in tissue thickness and enhanced cognitive ability (Narr et al., 2007; Luders, Narr, Thompson & Toga, 2009; Westlye, Lundervold, Rootwelt, Lundervold & Westlye, 2011; Sequeira & Ahmed, 2012). However, yoga therapy has shown that asana, pranayama, and meditation have been beneficial adjunct therapies in pain (Bormann et al., 2006; Orme et al., 2006; Segal et al., 2010; Zeidan, Johnson, Gordon & Goolkasian, 2010; Zeidan et al., 2011), posttraumatic stress disorder (Rosenthal, Grosswald, Ross & Rosenthal, 2011), anxiety (Khalsa et al., 1999; Brown & Gerbarg, 2005; Bormann et al., 2006; Ospina et al., 2008), depression (Nidich et al., 2009; Segal et al., 2010; Zeidan et al., 2010), and epilepsy (Orme-Johnson, 2006). Several studies have supported that it improves immune system associated with changed brain patterns (Davidson et al., 2003; Epel, Daubenmier, Moskowitz, Folkman & Blackburn, 2009; Pace et al., 2009; Effros, 2011; Jacobs et al., 2011) and also demonstrated that it improves chronic neurological disorders, stroke, multiple sclerosis, Alzheimer's disease, peripheral nervous system disease, and fibromyalgia (Mishra, Parampreet, Steven & Ray, 2012).
| Conclusion|| |
The purpose of this review is to analyze the effect of yoga therapy on ASD. It is particularly important to systematically study the aspects of both behavioral and human systems including musculoskeletal, cardiovascular, neurological, sensory integration, motor execution, communication, cognition, and social interaction. Children affected by this condition are not yet able to sit still and direct attention. Programs for autistic children that include chanting “om ”have been shown to synchronize respiratory signals, cardiovascular rhythms, and cerebral blood flow, entrain a particular brain activity or body rhythm, and create one-pointedness in the mind (Bernardi et al., 2001; Schmidt, Trainor & Santesso, 2003; Khalsa, Amen, Hanks, Money & Newberg, 2009; Khalsa, 2010; Sequeira & Ahmed, 2012). Ajmera et al. reported that pranayama with chanting (Pranava Pranayama) improved deep breathing patterns, thereby reducing anxiety and facilitating relaxation (Streeter et al., 2012; Ajmera et al., 2018).
Yoga is being identified as a treatment method that can optimize health outcomes for children with ASD. The reviewed literature suggests that yoga enhances children's emotional balance, cognitive power, and attention and decrease negative thought patterns, negative behavior, emotional and physical arousal, anxiety, and reactivity. As such, participation in yoga programs helps as a protective and curative factor for children with neurodevelopmental disorder or ASD. Longitudinal randomized controlled trials with strong methodological strategies are required to understand the health benefits of yoga programs delivered for the same.
Support of the management and administrators of Vinayaka Mission's Research Foundation for establishing and supporting the existence of the Center for Yogic Sciences (CYS) in the Aarupadai Veedu Medical College and Hospital at Pondicherry is gratefully acknowledged. We thank Prof. Dr. Madanmohan, Director, Centre for Yogic Sciences, AVMC, for his constant support, encouragement, and professional advice. We also thank management and administrators of Sri Balaji Vidyapeeth for establishing and supporting the work of CYTER where the current first author is pursuing his PhD in Yoga Therapy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Agnes, S. C., Queenie, Y. W., Sophia, L. S., Patrick, P. K. K, Yvonne, M. Y. H, & Mei-Chun, C. (2012). A Chinese Chan-based mind-body intervention improves sleep on patients with depression: A randomized controlled trial. The Scientific World Journal
Agnes, S. C., Queenie, Y. W., Sophia, L. S., Patrick, P. K. K, Yvonne, M. Y. H, & Mei-Chun, C. (2012). A Chinese Chan-based mind-body intervention for patients with depression. Journal of Affective Disorders
Ajmera, S., Sundar, S., Amirtha, G. B., Bhavanani, A. B., Dayanidy, G., & Ezhumalai, G. (2018). A comparative study on the effect of music therapy alone and a combination of music and yoga therapies on the psycho-physiological parameters of cardiac patients posted for angiography. Journal of Basic Clinical and Applied Health Science
Allen, S., & Anita, M. (2014). Yoga: Therapy for children on the autism spectrum. Academic Exchange Quarterly Summer
Amato, J. J., & Slavin, D. (1998). A preliminary investigation of oro motor function in young verbal and non-verbal children with autism. Infant-Toddler Intervention: The Transdisciplinary Journal
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Health Disorders-TR. American Psychiatric.
Andrea, D. G., Francesco, C., Vanessa, T., Annamaria, C., Maria, G. C., & Gianfranco, P. (2016). Aggressive behaviors and verbal communication skills in autism spectrum disorders. Global Pediatric Health
, 1-5. doi:10.1177/2333794X16644360.
Arora, N. K., Nair, M. K., Gulati, S., Deshmukh, V., Mohapatra, A., & Mishra, D., … Vajaratkar, V. (2018). Neurodevelopmental disorders in children aged 2±9 years: Population-based burden estimates across five regions in India. PLOS Medicine
(7), e1002615. doi:10.1371/journal.pmed.1002615.
Bachman, J. E., & Sluyter, D. (1988). Reducing inappropriate behaviors of developmentally disabled adults using antecedent aerobic dance exercises. Research in Developmental Disabilities
Baio, J., Wiggins, L., Christensen, D. L., Maenner, M. J., Daniels, J., & Warren, Z., … Dowling, N. F. (2018). Prevalence of autism spectrum disorder among children aged 8 years – Autism and developmental disabilities monitoring network, 11 sites, United States, 2014. MMWR Surveillance Summaries
(6), 1-23. doi:10.15585/mmwr.ss6706a1.
Baranek, G. T. (2002). Efficacy of sensory and motor interventions for children with autism. Journal of Autism and Developmental Disorders
Baron-Cohen, S. (2001). Theory of mind in normal development and autism. Prisme
Baron-Cohen, S., Leslie, A. M., & Frith, U. (1985). Does the autistic child have a “theory of mind”?. Cognition
Baron-Cohen, S., Ring, H. A., Bullmore, E. T., Wheelwright, S., Ashwin, C., & Williams, S. C. R. (2000). The amygdala theory of autism. Neuroscience and Biobehavioral Reviews
Bauman, M. L., & Kemper, T. L. (2005). Neuroanatomic observations of the brain in autism: A review and future directions. International Journal of Developmental Neuroscience
Bavin, E., Kidd, E., Predergast, L., Baker, E., Dissanayake, C., & Prior, M. (2014). Severity of autism is related to children's language processing. Autism Research
Begley, S. (2011). I can't think!. Newsweek
Belmonte, M. K., Tanushree, S. C., Ruth, C., Reema, M., Lisa, G., & Prathibha, K. (2013). Oral motor deficits in speech-impaired children with autism. Frontiers in Integrative Neuroscience
(47), 8. doi:10.3389/fnint.2013.00047.
Berger, D. L., Johnson-Silver, E., & Stein, R. (2009). Effects of yoga on inner-city children's well-being: A pilot study. Alternative Therapies in Health and Medicine
Bernardi, L., Sleight, P., Bandinelli, G., Cencetti, S., Fattorini, L., & Wdowczyc-Szulc, J., … Lagi, A. (2001). Effect of rosary prayer and yogamantras on autonomic cardiovascular rhythms: Comparative study. British Medical Journal
Betts, D. E., & Betts, S. W. (2006). Yoga for Children with Autism Spectrum Disorders
. Philadelphia, PA: Jessica Kingsley Publishers.
Bhat, A. N., Landa, R. J., & Galloway, J. C. (2011). Current perspectives on motor functioning in infants, children, and adults with autism spectrum disorders. Physical Therapy
Bhavanani, A. B., Udupa, K., Madanmohan, T., & Ravindra, P. N. (2011). A comparative study of slow and fast Surya Namaskar on physiological function. Int J Yoga
Boddaert, N., & Zilbovicius, M. (2002). Functional neuroimaging and childhood autism. Pediatric Radiology
Bormann, J. E., Becker, S., Gershwin, M., Kelly, A., Pada, L., & Smith, T. L., … Gifford, A. L. (2006). Relationship of frequent mantram repetition to emotional and spiritual wellbeing in healthcare workers. Journal of Continuing Education in Nursing
Bormann, J. E., Gifford, A. L., Shively, M., Smith, T. L., Redwine, L., & Kelly, A., … Belding, W. (2006). Effects of spiritual mantram repetition on HIV outcomes: A randomized controlled trial. Journal of Behavioral Medicine
Bremer, E., Crozier, M., & Lloyd, M. (2016). A systematic review of the behavioural outcomes following exercise interventions for children and youth with autism spectrum disorder. Autism
(8), 899-915. doi:10.1177/1362361315616002.
Brian, A. B., Matthew, M., Tia, H., Grace, T. B., & James, W. B. (2009). Relationships among repetitive behaviors, sensory features, and executive functions in high functioning autism. Research in Autism Spectrum Disorders
(4), 959-966. doi:10.1016/j.rasd.2009.05.003.
Brouwer, W. B., van Exel, N. J., Koopmanschap, M. A., & Rutten, F. F. (1999). The valuation of informal care in economic appraisal. A consideration of individual choice and societal costs of time. International Journal of Technology Assessment in Health Care
Brown, R. P., & Gerbarg, P. L. (2005). Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression: Part I–neurophysiologic model. Journal of Alternative and Complementary Medicine
Calhoun, M., Longworth, M., & Chester, V. L. (2011). Gait patterns in children with autism. Clinical Biomechanics (Bristol, Avon)
Case-Smith, J., & Bryan, T. (1999). The effects of occupational therapy with sensory integration emphasis on preschool-age children with autism. American Journal of Occupational Therapy
Celiberti, D. A., Heather, E. B., Kimberly, S. K., Sandra, L. H., & Jan, S. H. (1997). The differential and temporal effects of antecedent exercise on the self-stimulatory behavior of a child with autism. Research in Developmental Disabilities
Chan, A. S., Sophia, L. S., Siu, N. Y., Lau, E. M., & Cheung, M. C. (2013). A Chinese mind-body exercise improves self-control of children with autism: A randomized controlled trial. PLoS ONE
(7), e68184. doi:10.1371/journal.pone.0068184.
Chen, K. W., Berger, C. C., Manheimer, E., Forde, D., Magidson, J., & Dachman, L.,... Lejuez, C. W. (2012). Meditative therapies for reducing anxiety: A systematic review and meta-analysis of randomized controlled trials. Depression and Anxiety
Cherkassky, V. L., Kana, R. K., Keller, T. A., & Just, M. A. (2006). Functional connectivity in a baseline resting-state network in autism. NeuroReport
Christopher, L., Jennifer, A. T., Jeffery, D. F., Marcus, L. T., Martin, A. V., & Gloria, K. L. (2013). Prevalence and predictors of psychotropic use in children with high-functioning ASDs. Autism Research and Treatment
, 384527. doi:10.1155/2013/384527.
Davidson, R. J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M., Muller, D., & Santorelli, S. F., … Sheridan, J. F. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine
Dawson, G., Munson, J., Estes, A., Osterling, J., McPartland, J., & Toth, K. (2002). Neurocognitive function and joint attention ability in young children with autism spectrum disorder versus developmental delay. Child Development, 73
Dawson, G., & Watling, R. (2000). Interventions to facilitate auditory, visual, and motor integration in autism: A review of the evidence. Journal of Autism and Developmental Disorders, 30
Dinesh, T., Girwar, S. G., Vivek, K. S., Ananda, B. B., Rajajeyakumar, M., & Syam, S. A. (2014). Effect of slow and fast pranayama training on handgrip strength and endurance in healthy volunteers. Journal of Clinical and Diagnostic Research, 8
Dinstein, I., Pierce, K., Eyler, L., Solso, S., Malach, R., & Behrmann, M., … Courchesne, E. (2011). Disrupted neural synchronization in toddlers with autism. Neuron, 70
Effros, R. B. (2011). Telomere/telomerase dynamics within the human immune system: effect of chronic infection and stress. Experimental Gerontology, 46
Epel, E., Daubenmier, J., Moskowitz, J. T., Folkman, S., & Blackburn, E. (2009). Can meditation slow rate of cellular aging? Cognitive stress, mindfulness, and telomeres. Annals of the New York Academy of Sciences
Eric, S. (2012). Teacher education in autism spectrum disorders: A potential blueprint. Education and Training in Autism and Developmental Disabilities, 47
Gahan, J. P., Cynthia, A. B., Eriene, Y., Zhu, Y., & Fiona, D. (2007). Risperidone improves behavioral symptoms in children with autism in a randomized, double-blind, placebo-controlled trial. Journal of Autism and Developmental Disorders
, 367-373. doi:10.1007/s10803-006-0234-7.
Gepner, B., & Feron, F. (2009). Autism: A world changing too fast for a mis-wired brain? Neuroscience & Biobehavioral Reviews
Gepner, B., & Mestre, D. (2002). Rapid visual-motion integration deficit in autism. Trends in Cognitive Sciences
Giblin, L. B., de Leon, L., Smith, L. M., Sztynda, T., & Lal, S. (2013). Heart rate variability, blood pressure and cognitive function: Assessing age effects. River Publishers
Gillberg, C. (2010). The essence in child psychiatry: Early symptomatic syndromes eliciting neuro-developmental clinical examinations. Research in Developmental Disabilities
, 1543-1551. doi:10.1016/j.ridd.2010.06.002.
Goldberg, L. (2004). Creative relaxation: A yoga-based program for regular and exceptional student education. International Journal of Yoga Therapy, 14
Green, D., Charman, T., Pickles, A., Chandler, S., Loucas, T., & Simonoff, E.,... Baird, G. (2009). Impairment in movement skills of children with autistic spectrum disorders. Developmental Medicine & Child Neurology, 51
Grosse, S. D., Prosser, L. A., Asakawa, K., & Feeny, D. (2010). QALY weights for neurosensory impairments in pediatric economic evaluations: Case studies and a critique. Expert Review of Pharmacoeconomics & Outcomes Research
Gulati, K., Loganathan, N., Mooventhan, A., Lahiri, A., & Telles, S. (2018). Effect of yoga therapy on the symptoms of sensory processing disorder in autistic individuals. Yoga Mimamsa
Guyenet, P. G., Koshiya, N., Huangfu, D., Baraban, S. C., Stornett, R. I., & Li, Y. W. (1996). Role of medulla oblongata in generation of sympathetic and vagal outflows. In: Holstege, G., Bandler, R., & Saper, C. B., (Eds). The Emotional Motor System
. Amsterdam: Elsevier, 127-144.
Gwynette, M. F., Warren, N. J., Warthen, J., Truleove, J. S., Ross, C. P., & Snook, C. A. (2015). Yoga as an intervention for patients with autism spectrum disorder: A review of the evidence and future directions. Autism Open Access
, 1000155. doi:10.4172/21657890.1000155.
Happe, F., & Frith, U. (1996). The neuropsychology of autism. Brain
119 (Pt 4), 1377-1400.
Hardan, A. Y., Kilpatrick, M., Keshavan, M. S., & Minshew, N. J. (2003). Motor performance and anatomic magnetic resonance imaging (MRI) of the basal ganglia in autism. Journal of Child Neurology
Helen, E. P. (2006). Neurobiological correlates of autism: A review of recent research, child neuropsychology. A Journal on Normal and Abnormal Development in Childhood and Adolescence
Herrero, D., Crocetta, T. B., Massetti, T., Moraes, Í. A. P., Trevizan, I. L., & Guarnieri, R. (2015). Total reaction time performance of individuals with autism after a virtual reality task. International Journal of Neurorehabilitation
(5), 189-194. doi:10.4172/2376-0281.1000189.
Hirstein, W., Iversen, P., & Ramachandran, V. S. (2001). Autonomic responses of autistic children to people and objects. Proceedings of the Royal Society B: Biological Sciences
Horsman, J., Furlong, W., Feeny, D., & Torrance, G. (2003). The health utilities index (HUI): Concepts, measurement properties and applications. Health and Quality of Life Outcomes
Hourston, S., & Atchley, R. (2017). Autism and mind-body therapies: A systematic review. The Journal of Alternative and Complementary Medicine
(5), 331-339. doi:10.1089/acm.2016.0336.
Huebner, R. A. (2001). Autism: A Sensorimotor Approach to Management
. Gaithersburg, MD: Aspen Publishers.
Hughes, J. R. (2007). Autism: The first firm finding under connectivity?. Epilepsy and Behavior
Iacoboni, M., & Dapretto, M. (2006). The mirror neuron system and the consequences of its dysfunction. Nature Reviews Neuroscience
Ikeda, E., Hinckson, E., & Krageloh, C. (2014). Assessment of quality of life in children and youth with autism spectrum disorder: A critical review. Quality of Life Research
Jacobs, T. L., Epel, E. S., Lin, J., Blackburn, E. H., Wolkowitz, O. M., & Bridwell, D. A,... Saron, C. D. (2011). Intensive meditation training, immune cell telomerase activity, and psychological mediators. Psychoneuroendocrinology
Johnny, L. M., & Julie, A. H. (2011). Psychotropic drug efficacy and side effects for persons with autism spectrum disorders. Research in Autism Spectrum Disorders, 5
, 230-236. doi:10.1016/j.rasd.2010.04.004.
Jones, H. P., Guildea, Z. E., Stewart, J. H., & Cartlidge, P. H. (2002). The health status questionnaire: Achieving concordance with published disability criteria. Archives of Disease in Childhood
Jong, D. M., Punt, M., Groot, D. E., Minderaa, R. B., & Hadders, A. M. (2011). Minor neurological dysfunction in children with autism spectrum disorder. Developmental Medicine & Child Neurology
Jordan, D. (1995). Central nervous integration of cardiovascular regulation. In: Jordan, D., & Marshall, J., (Eds). Cardiovascular Regulation
(pp. 1-14). London: Portland Press.
Julu, P. O. O., Kerr, A. M., Hansen, S., Apartopoulos, F., & Jamal, G. A. (1997). Functional evidence of brain stem immaturity in Rett syndrome. European Child & Adolescent Psychiatry
Kana, R. K., Keller, T. A., Minshew, N. J., & Just, M. A. (2007). Inhibitory control in high-functioning autism: Decreased activation and underconnectivity in inhibition networks. Biological Psychiatry
Karanth, P. (2007). Communication DEALL Developmental Checklists
. Bangalore: Com DEALL Trust.
Keele, C. A., Neil, E., & Joels, N., (Eds.). (1982). Neural control of the cardiovascular system. In: Samson Wright's Applied Physiology
(pp. 123-133). New York: Oxford University Press.
Kenny, M. S. (2002). Integrated movement therapy™: Yoga-based therapy as a viable and effective intervention for autism spectrum and related disorders. International Journal of Yoga Therapy
Kern, J. K., Geier, D. A., Adams, J. B., Troutman, M. R., Davis, G. A., & King, P. G.,... Geier, M. R. (2013). Handgrip strength in autism spectrum disorder compared with controls. The Journal of Strength and Conditioning Research
Kern, L., Koegel, R. L., & Dunlap, G. (1984). The influence of vigorous versus mild exercise on autistic stereotyped behaviors. Journal of Autism and Developmental Disorders
Khalsa, D. S. (2010). Kundalini Yoga Meditation for Complex Psychiatric Disorders: Techniques Specific for Treating the Psychoses, Personality, and Pervasive Developmental Disorders
. New York, USA: WW Norton & Company.
Khalsa, D. S., Amen, D., Hanks, C., Money, N., & Newberg, A. (2009). Cerebral blood flow changes during chanting meditation. Nuclear Medicine Communications
Khalsa, D. S., Ray, L. E., Levine, S., Gallen, C. C., Schwartz, B. J., & Sidorowich, J. J. (1999). Randomized controlled trial of yogic meditation techniques for patients with obsessive-compulsive disorder. CNS Spectrums, 4
Koenig, K., Pfeiffer, B. A., Moya, K., Megan, S., & Lorrie, H. (2011). Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, 65
Koenig, K. P., Buckley-Reen, A., & Garg, S. (2012). Efficacy of the get ready to learn yoga program among children with autism spectrum disorders: A pretest-posttest control group design. American Journal of Occupational Therapy
, 538-546. doi:10.5014/ajot.2012.004390.
Koyeli, S., Leera, L., & Vibha, K. (2015). Educational and behavioral interventions in management of autism spectrum disorder. Indian Journal of Pediatrics
Larson, J. L., & Miltenberger, R. G. (1992). The influence of antecedent exercise on problem behaviors in persons with mental retardation: A failure to replicate. Journal of the Association for persons with Severe Handicaps
Leary, M. R., & Hill, D. A. (1996). Moving on: Autism and movement disturbance. Ment Retard, 34
Lieberman, A., & Pointer, M. D. H. (2008). Teacher learning: The key to educational reform. Journal of Teacher Education
Limbers, C. A., Ripperger-Suhler, J., Heffer, R. W., & Varni, J. W. (2011). Patient-reported Pediatric quality of life inventory™ 4.0 generic core scales in pediatric patients with attention-deficit/hyperactivity disorder and comorbid psychiatric disorders: Feasibility, reliability, and validity. Value in Health
Linderman, T. M., & Stewart, K. B. (1999). Sensory integrative-based occupational therapy and functional outcomes in young children with pervasive developmental disorders: A single-subject study. American Journal of Occupational Therapy
Lonigan, C. J., Elbert, J. C., & Johnson, S. B. (1998). Empirically supported psychosocial interventions for children: An overview. Journal of Clinical Child & Adolescent Psychology
Lord, C., & Bishop, S. L. (2010). Autism spectrum disorders: Diagnosis, prevalence, and services for children and families. Social Policy Report 24
Luders, E., Narr, K. L., Thompson, P. M., & Toga, A. W. (2009). Neuroanatomical correlates of intelligence. Intelligence
Luyster, R. J., Kadlec, M. B., Carter, A., & Tager-Flusberg, H. (2008). Language assessment and development in toddlers with autism spectrum disorders. Journal of Autism and Developmental Disorders
Lynch, S., & Irvine, A. (2009). Inclusive education and best practice for children with autism spectrum disorder: An integrated approach. International Journal of Inclusive Education
Mandanmohan, T., Lakshmi, J., Kaviraja, U., & Ananda, B. B. (2003). Effect of yoga training on handgrip, respiratory pressures and pulmonary function. Indian Journal of Physiology and Pharmacology
Manjunath, N., & Telles, S. (2001). Improved performance in the tower of London test following yoga. Indian Journal of Physiology and Pharmacology
Markramand, K., & Markram, H. (2010). The intense world theory – A unifying theory of the neurobiology of autism. Frontiers in Human Neuroscience, 4
Mayes, S. T., & Calhoun, S. I. (1999). Symptoms of autism in young children and correspondence with the DSM. Infants and Young Children
McArdle, F. (2010). Preparing quality teachers: Making learning visible. Australian Journal of Teacher Education, 35
Michelle, L., Serwacki, B. A., & Catherine, C. C. (2012). Yoga in the schools: A systematic review of the literature. International Journal of Yoga Therapy
Miller, L. J., Schoen, S. A., James, K., & Schaaf, R. C. (2007). Lessons learned: A pilot study on occupational therapy effectiveness for children with sensory modulation disorder. American Journal of Occupational Therapy
Ming, X., Brimacombe, M., & Wagner, G. C. (2007). Prevalence of motor impairment in autism spectrum disorders. Brain and Development
Ming, X., Peter, O. O. J., Michael, B., Susan, C., & Mary, L. D. (2005). Reduced cardiac parasympathetic activity in children with autism. Brain and Development
, 509-516. doi:10.1016/j.braindev.2005.01.003.
Minshew, N. J., Sung, K., Jones, B. L., & Furman, J. M. (2004). Underdevelopment of the postural control system in autism. Neurology
Mishra, K., Parampreet, S., Steven, J. B., & Ray, Z. (2012). The therapeutic value of yoga in neurological disorders. Annals of Indian Academy of Neurology
Mitchell, S., Brian, J., Zwaigenbaum, L., Roberts, W., Szatmari, P., & Smith, I., … Bryson, S. (2006). Early language and communication development of infants later diagnosed with autism spectrum disorder. Journal of Developmental and Behavioral Pediatrics
Moffitt, T. E., Arseneault, L., Belsky, D., Dickson, N., Hancox, R. J., & Harrington, H., … Caspi, A. (2011). A gradient of childhood self-control predicts health, wealth, and public safety. Proceedings of the National Academy of Sciences of the United States of America
Moodie, M., Richardson, J., Rankin, B., Iezzi, A., & Sinha, K. (2010). Predicting time trade-off health state valuations of adolescents in four Pacific countries using the assessment of quality-of-life (AQoL-6D) instrument. Value in Health
Murias, M., Webb, S. J., Greenson, J., & Dawson, G. (2007). Resting state cortical connectivity reflected in EEG coherence in individuals with autism. Biological Psychiatry
Narr, K. L., Woods, R. P., Thompson, P. M., Szeszko, P., Robinson, D., & Dimtcheva, T., … Bilder, R. M. (2007). Relationships between IQ and regional cortical gray matter thickness in healthy adults. Cerebral Cortex
Natasha, M., Heather, U. R., Fellana, R., Zhang, Y., & John, N. C. (2014). Lack of effect of risperidone on core autistic symptoms: Data from a longitudinal study. Journal of Child and Adolescent Psychopharmacology
(9), 513-518. doi:10.1089/cap.2014.0055.
Nemeroff, C. B., Mayberg, H. S., Krahl, S. E., McNamara, J., Frazer, A., & Henry, T. R., … Brannan, S. K. (2006). VNS therapy in treatment-resistant depression: clinical evidence and putative neurobiological mechanisms. Neuropsychopharmacology
Newberg, A. B., Wintering, N., Khalsa, D. S., Roggenkamp, H., & Waldman, M. R. (2010). Meditation effects on cognitive function and cerebral blood flow in subjects with memory loss: A preliminary study. Journal of Alzheimer's Disease
Nidich, S. I., Rainforth, M. V., Haaga, D. A. F., Hagelin, J., Salerno, J. W., & Travis, F., … Schneider, R. H. (2009). A randomized controlled trial on effects of the transcendental meditation program on blood pressure, psychological distress, and coping in young adults. American Journal of Hypertension
Noterdaeme, M., Mildenberger, K., Minow, F., & Amorosa, H. (2002). Evaluation of neuromotor deficits in children with autism and children with a specific speech and language disorder. European Child and Adolescent Psychiatry
, 219-225. doi:10.1007/s00787-002-0285-z.
Orme-Johnson, D. (2006). Evidence that the transcendental meditation program prevents or decreases diseases of the nervous system and is specifically beneficial for epilepsy. Medical Hypotheses, 67
Orme-Johnson, D. W., Schneider, R. H., Son, Y. D., Nidich, S., & Cho, Z. H. (2006). Neuroimaging of meditation's effect on brain reactivity to pain. NeuroReport
Ospina, M. B., Bond, K., Karkhaneh, M., Buscemi, N., Dryden, D. M., & Barnes, V., … Shannahoff-Khalsa, D. (2008). Clinical trials of meditation practices in health care: Characteristics and quality. Journal of Alternative and Complementary Medicine
Pace, T. W. W., Negi, L. T., Adame, D. D., Cole, S. P., Sivilli, T. I., & Brown, T. D., … Raison, C. L. (2009). Effect of compassion meditation on neuroendocrine, innate immune and behavioral responses to psychosocial stress. Psychoneuroendocrinology
Palkovitz, R. J., & Wiesenfeld, A. R. (1980). Differential autonomic responses of autistic and normal children. Journal of Autism and Developmental Disorders
Payakachat, N., Tilford, J. M., Kovacs, E., & Karen, K. (2012). Autism spectrum disorders: A review of measures for clinical, health services and cost-effectiveness applications. Expert Review of Pharmacoeconomics and Outcomes Research
(4), 485-503. doi:10.1586/erp.12.29.
Peck, H. L., Kehle, T. J., Bray, M. A., & Theodore, L. A. (2005). Yoga as an intervention for children with attention problems. School Psychology Review, 34
Petrou, S. (2003). Methodological issues raised by preference-based approaches to measuring the health status of children. Health Economics
Polenick, C. A., & Flora, S. R. (2012). Sensory integration and autism: Science or pseudoscience?. Skeptic
Provost, B., Heimerl, S., & Lopez, B. R. (2007). Levels of gross and fine motor development in young children with autism spectrum disorder. Physical & Occupational Therapy In Pediatrics, 27
Raat, H., Botterweck, A. M., Landgraf, J. M., Hoogeveen, W. C., & Essink-Bot, M. L. (2005). Reliability and validity of the short form of the child health questionnaire for parents (CHQ-PF28) in large random school based and general population samples. Journal of Epidemiology and Community Health
Raat, H., Landgraf, J. M., Bonsel, G. J., Gemke, R. J., & Essink-Bot, M. L. (2002). Reliability and validity of the child health questionnaire – Child form (CHQ-CF87) in a Dutch adolescent population. Quality of Life Research
Radhakrishna, S., Nagarathna, R., & Nagendra, H. R. (2010). Integrated approach to yoga therapy and autism spectrum disorders. Journal of Ayurveda & Integrative Medicine
Raghuraj, P., & Telles, S. (2003). A randomized trial comparing the effects of yoga and physical activity programs on depth perception in school children. Indian Journal of Psychology, 21
Ravens-Sieberer, U., Auquier, P., Erhart, M., Gosch, A., Rajmil, L., Bruil, J., Power, M., Duer, W., Cloetta, B., Czemy, L., Mazur, J., Czimbalmos, A., Tountas, Y., Hagquist, C., Kilroe, J., European KIDSCREEN Group. (2007). The KIDSCREEN-27 quality of life measure for children and adolescents: psychometric results from a cross-cultural survey in 13 European countries. Qual Life Res
, 16(8), 1347-1356.
Ravens-Sieberer, U., Wille, N., Badia, X., Bonsel, G., Burström, K., & Cavrini, G., … Greiner, W. (2010). Feasibility, reliability, and validity of the EQ-5D-Y: Results from a multinational study. Quality of Life Research
Riley, A. W., Forrest, C. B., Rebok, G. W., Starfield, B., Green, B. F., & Robertson, J. A., … Friello, P. (2004). The child report form of the CHIP-child edition: Reliability and validity. Medical Care
Riley, A. W., Forrest, C. B., Starfield, B., Green, B., Kang, M., & Ensminger, M. (1998). Reliability and validity of the adolescent health profile-types. Medical Care
Roberts, J. E., King-Thomas, L., & Boccia, M. L. (2007). Behavioral indexes of the efficacy of sensory integration therapy. American Journal of Occupational Therapy
Rojahn, J., Matson, J. L., Lott, D., Esbensen, A. J., & Smalls, Y. (2001). The behavior problems inventory: An instrument for the assessment of self-injury, stereotyped behavior, and aggression/destruction in individuals with developmental disabilities. Journal of Autism and Developmental Disorders
Rosenblatt, L. E., Gorantla, S., Torres, J. A., Yarmush, R. S., Rao, S., & Park, E. R., … Levine, J. B. (2011). Relaxation response-based yoga improves functioning in young children with autism: A pilot study. The Journal of Alternative and Complementary Medicine
Rosenthal, J. Z., Grosswald, S., Ross, R., & Rosenthal, N. (2011). Effects of transcendental meditation in veterans of operation enduring freedom and operation Iraqi freedom with post traumatic stress disorder: A pilot study. Military Medicine
Rushmer, R. F. (Ed.). (1972). Systemic arterial pressure. In: Structure and Function of the Cardiovascular System
(pp. 148-191.). London: W.B. Saunders.
Sacrey, L. A. R., Germani, T., Bryson, S. E., & Zwaigenbaum, L. (2014). Reaching and grasping in autism spectrum disorder: A review of recent literature. Frontiers in Neurology
Sarris, J., & Byrne, G. (2011). A systematic review of insomnia and complementary medicine. Sleep Medicine Reviews
Schaaf, R. C., & Miller, L. J. (2005). Occupational therapy using a sensory integrative approach for children with developmental disabilities. Mental Retardation and Developmental Disabilities Research Reviews
Schaaf, R. C., & Nightlinger, K. M. (2007). Occupational therapy using a sensory integrative approach: A case study of effectiveness. American Journal of Occupational Therapy
Schmidt, L. A., Trainor, L. J., & Santesso, D. L. (2003). Development of frontal electroencephalogram (EEG) and heart rate (ECG) responses to affective musical stimuli during the first 12 months of post-natal life. Brain and Cognition
Segal, Z. V., Bieling, P., Young, T., MacQueen, G., Cooke, R., & Martin, L., … Levitan, R. D. (2010). Antidepressant monotherapy vs. sequential pharmacotherapy and mindfulness based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Archives of General Psychiatry
Seiber, W. J., Groessl, E. J., Ganiats, T. G., & Kaplan, R. M. (2008). Quality of Well Being Self- Administered (QWB-SA) Scale: User's Manual
. Health Services Research Center, University of California, CA, USA.
Sequeira, S., & Ahmed, M. (2012). Meditation as a potential therapy for autism: A review. Autism Research and Treatment, 2012
, 835847. doi:10.1155/2012/835847.
Singer, A., & Ramita, R. (2015). Complementary and alternative treatments for autism part 2: Identifying and avoiding non-evidence-based treatments. AMA Journal of Ethics
Smith, S. A., Press, B., Koenig, K. P., & Kinnealey, M. (2005). Effects of sensory integration intervention on self-stimulating and self-injurious behaviors. American Journal of Occupational Therapy
Stahmera, A. C., Schreibmanb, L., & Cunningham, A. B. (2011). Toward a technology of treatment individualization for young children with autism spectrum disorders. Brain Research
Stein, R. E., & Jessop, D. J. (1990). Functional status II(R). A measure of child health status. Medical Care
Stephen, B., & Robert, L. H. (2015). Complementary and alternative treatments for autism Part 1: Evidence-supported treatments. AMA Journal of Ethics
Stevens, K. (2009). Developing a descriptive system for a new preference-based measure of health-related quality of life for children. Quality of Life Research
Streeter, C. C., Gerbarg, P. L., Saper, R. B., Ciraulo, D. A., & Brown, R. P. (2012). Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Medical Hypotheses
(5), 571-579. doi:10.1016/j.mehy.2012. 01.021.
Suresh, P. A. (2018). Global prevalence of autism: A mini-review. SciFed Journal of Autism, 2
Thayer, J. F., & Brosschot, J. F. (2005). Psychosomatics and psychopathology: Looking up and down from the brain. Psychoneuroendocrinology, 30
Thayer, J. F., Hansen, A. L., Saus-Rose, E., & Johnsen, B. H. (2009). Heart rate variability, prefrontal neural function, and cognitive performance: The neurovisceral integration perspective on self-regulation, adaptation, and health. Annals of Behavioral Medicine
(2), 141-153. doi:10.1007/s12160-009-9101-z.
Thurm, A., Lord, C., Lee, L., & Newschaffer, C. (2007). Predictors of language acquisition in preschool children with autism spectrum disorders. Journal of Autism and Developmental Disorders
, 1721-1734. doi:10.1007/s10803-006-0300-1.
Tilford, J. M. (2002). Cost-effectiveness analysis and emergency medical services for children: Issues and applications. Ambulatory Pediatrics, 2
Tissot, C., & Evans, R. (2003). Visual teaching strategies for children with autism. Early Child Development and Care
(4), 425-433. doi:10.1080/0300443032000079104.
Tomchek, S. D., & Dunn, W. (2007). Sensory processing in children with and without autism: A comparative study using the short sensory profile. American Journal of Occupational Therapy
Varni, J. W., Burwinkle, T. M., Seid, M., & Skarr, D. (2003). The PedsQL 4.0 as a pediatric population health measure: Feasibility, reliability, and validity. Ambulatory Pediatrics
Veague, H. B. (2010). Autism
. New York: Chelsea House Publishers.
Wahbeth, H., Elsas, S., & Oken, B. (2008). Mind-body interventions: Applications in neurology. Neurology
Waldie, K., & Saunders, A. (2014). The neural basis of autism: A review. International Journal of School and Cognitive Psychology
, 113. doi:10.4172/2469-9837.1000113.
Wallace, G. L., Dankner, L., Kenworthy, L., Giedd, J. N., & Martin, A. (2010). Age-related temporal and parietal cortical thinning in autism spectrum disorders. Brain
Waterhouse, L., & Fein, D. (1982). Language skills in developmentally disabled children. Brain and Language
Watling, R., Deitz, J., Kanny, E. M., & McLaughlin, J. F. (1999). Current practice of occupational therapy for children with autism. American Journal of Occupational Therapy, 53
Watling, R. L., & Dietz, J. (2007). Immediate effect of Ayres's sensory integration–based occupational therapy intervention on children with autism spectrum disorders. American Journal of Occupational Therapy
Watters, R. G., & Watters, W. E. (1980). Decreasing self-stimulatory behavior with physical exercise in a group of autistic boys. Journal of Autism and Developmental Disorders
Weaver, L. L. (2015). Effectiveness of work, activities of daily living, education, and sleep interventions for people with autism spectrum disorder: A systematic review. American Journal of Occupational Therapy
, 6905180020. doi:10.5014/ajot.2015.017962.
Westlye, E. T., Lundervold, A., Rootwelt, H., Lundervold, A. J., & Westlye, L. T. (2011). Increased hippocampal default mode synchronization during rest in middle-aged and elderly APOE & 4 carriers: Relationships with memory performance. Journal of Neuroscience, 31
Wilbarger, P., & Wilbarger, J. (1991). Sensory Defensiveness in Children Aged 2 – 12: An Intervention Guide for Parents and Other Caregivers
. Denver, C.O.: Avanti Educational Programs.
Yeh, G., Wang, C., Wayne, P., & Phillips, R. (2009). Tai chi exercise for patients with cardiovascular conditions and risk factors: A systematic review. Journal of Cardiopulmonary Rehabilitation and Prevention, 29
Zeidan, F., Johnson, S. K., Gordon, N. S., & Goolkasian, P. (2010). Effects of brief and sham mindfulness meditation on mood and cardiovascular variables. Journal of Alternative and Complementary Medicine
Zeidan, F., Martucci, K. T., Kraft, R. A., Gordon, N. S., Mchaffie, J. G., & Coghill, R. C. (2011). Brain mechanisms supporting the modulation of pain by mindfulness meditation. Journal of Neuroscience
[Table 1], [Table 2]