THE ROLES OF TOUCHING AND MASSAGE AMONG OCCUPATIONAL THERAPISTS AND TEACHERS IN EARLY INTERVENTION PROGRAMS Except where reference is made to the work of others, the work described in this dissertation is my own or was done in collaboration with my advisory committee. This dissertation does not include proprietary or classified information. _____________________________________ Gwendolyn Gray Certificate of Approval: Phillip Browning AmySue Reilly, Chair Professor Associate Professor Rehabilitation and Special Education Rehabilitation and Special Education Karen Rabren Rebecca Curtis Associate Professor Assistant Professor Rehabilitation and Special Education Rehabilitation and Special Education Margaret Shippen George T. Flowers Assistant Professor Dean Rehabilitation and Special Education Graduate THE ROLES OF TOUCHING AND MASSAGE AMONG OCCUPATIONAL THERAPISTS AND TEACHERS IN EARLY INTERVENTION PROGRAMS Gwendolyn Gray A Dissertation Submitted to the Graduate Faculty of Auburn University In Partial Fulfillment of the Requirements for the Degree of Doctor of Education Auburn, Alabama December 19, 2008 THE ROLES OF TOUCHING AND MASSAGE AMONG OCCUPATIONAL THERAPISTS AND TEACHERS IN EARLY INTERVENTION PROGRAMS Gwendolyn Gray Permission is granted to Auburn University to make copies of this dissertation at its discretion, upon request of individuals or institutions at their expense. The author reserves all publication rights. Signature of Author Date of Graduation iii VITA Gwendolyn Gray was born to Lincoln and Elizabeth Gray in Birmingham Alabama. After completing elementary and secondary school in Birmingham, Alabama, she attended the University of Alabama at Birmingham and completed a Bachelor of Science degree in occupational therapy and a Master of Arts degree in education with a major in Special Education. After completing her bachelor’s degree, she worked as a staff therapist for eight years at United Cerebral Palsy of Greater Birmingham (UCP). During this time she returned to school to complete a Master’s degree. After leaving UCP of Greater Birmingham, she worked at Hill Crest Hospital, a private emotional and behavioral health facility in Birmingham for four years as the Head of Occupational Therapy. In August of 1984 she joined the faculty at Tuskegee University in the undergraduate occupational therapy program as an instructor. For the next fifteen years, she continued a faculty practice in public and private school systems in Eufaula, Macon, Montgomery, Lee, and Auburn City school districts and Project AIM. Today she is an assistant professor and since 1999 has served as the Director of the Occupational Therapy program at Tuskegee University. After the profession of occupational therapy moved to an entry level master’s degree, she returned to school to earn a doctor of philosophy degree at Auburn University in Rehabilitation and Special Education, specializing in early intervention. iv DISSERTATION ABSTRACT THE ROLES OF TOUCHING AND MASSAGE AMONG OCCUPATIONAL THERAPISTS AND TEACHERS IN EARLY INTERVENTION PROGRAMS Gwendolyn Gray Doctor of Philosophy, December 19, 2008 (M.A., University of AL in Birmingham, 1977) (B.S., University of AL in Birmingham, 1972) 168 Typed Pages Directed by AmySue Reilly The purpose of this study was to determine what occupational therapists and teachers in early intervention programs know about touching and massage; their personal attitudes about touching and being touched; and their practices regarding the use of touch/massage with infants and children with special needs from 0 to 3 years of age. The survey instrument was pilot tested for psychometric properties (test-retest reliability, and factor analysis) with student volunteers from Auburn and Tuskegee Universities. The survey was then mailed to a sample of occupational therapists nationally and teachers in early intervention programs in Alabama. With a follow up postcard, the return rate was 31% (n = 336). v Based on statistical analyses, the survey instrument was determined to be a valid and reliable device for measuring the population under study. Using probability statistics, two of the three null hypotheses were retained and one was rejected. The following conditions were statistically significant: (a) number correct (knowledge) by work experience; (b) number correct by professional position; (c) avoid touch factor (attitude) by work experience; (d) avoid touch factor by highest degree; (e) will practice factor (practice) by license to massage; and (f) will practice factor by complementary and alternative medicines (CAM). Being an occupational therapist or teacher in early intervention was only statistically significant as it related to knowledge. The multiple regressions predicted that the more knowledge a participant has about touch, massage and CAMs, the more willing they were to use these interventions in practice. And the reverse was also predicted: where there is an attitude of more touch avoidance a participant would practice touch/massage less often in intervention. The respondents who commented on the study stated that they were supportive of CAMs, massage and touch-related intervention. Two hundred and thirty seven of the respondents were trained in other CAMs. The most frequent CAM training was myofascial release and massage training. The results were predictable. The analyses presented evidence that work experience and any CAM training (including massage) were statistically significant rather than professional position (teacher or therapist) as it related to attitudes about touching and a willingness to practice massage or other CAMs. vi ACKNOWLEDGMENTS The author would like to thank Dr. Jim Gundlach for assistance with statistical analyses and my dissertation committee for their guidance and help. Special thanks are also due to the Chair of my committee, Dr. AmySue Reilly, and other students, staff members and professors at Auburn University and Tuskegee University who encouraged, cajoled, and believed that the author could get this investigation done. Thanks are especially due to family and friends who prayed and supported the author during this investigation. vii Style manual or journal used: Publication Manual of the American Psychological Association (5th ed.) Computer software used: Microsoft Word 2007, JMP (version 7) of Statistical Analysis Systems (SAS) viii TABLE OF CONTENTS LIST OF TABLES ..................................................................................................... xii I. INTRODUCTION ......................................................................................... 1 Overview of Early Intervention ..................................................................... 2 IDEA Legislation ............................................................................... 3 History of Early Intervention and Early Childhood Special Education ................................................. 4 Overview of Occupational Therapy in Early Intervention ............................ 6 Federal Legislative Influence on Occupational Therapy ................... 7 Purpose of Study and Hypotheses.................................................................. 10 Therapeutic Principles of Touch and Massage .............................................. 10 Complementary and Alternative Medicines ...................................... 11 Theoretical Frame of Reference ......................................................... 12 Significance of Study ..................................................................................... 13 II. REVIEW OF LITERATURE ........................................................................ 17 Understanding Sensory Systems .................................................................... 17 The Brain and Touch ......................................................................... 18 Structure and Function of Human Skin ............................................. 19 Massage and Pain Reduction ............................................................. 23 Nature of Human Touch: Types and Patterns .................................... 25 History of Massage and Touching for Therapy ............................................. 28 Ancient Civilization ........................................................................... 28 The Middle Ages................................................................................ 31 The Nineteenth Century ..................................................................... 31 ix Massage in the United States ............................................................. 32 Touch Deprivation Studies ............................................................................ 34 Summary of Mary Carlson’s Work in Romanian Orphanages .......... 40 Tronick and Morelli Cross-Cultural Studies in Zaire and Mother-Infant Interactions .............................................. 47 Touch Among the Efe ............................................................ 48 Touch During Face-to-Face Interactions ............................... 50 Aversion to Touch.............................................................................. 53 Massage Theory and Techniques ................................................................... 55 Theory and Indications for Use .......................................................... 55 Overview of Manual Techniques ....................................................... 57 Contraindications for Massage/Touch ............................................... 59 Infant Massage Techniques................................................................ 60 Touch During Pregnancy, Labor and Delivery .............................................. 62 TRI Research on Infant Massage ................................................................... 64 Some Multidisciplinary Uses of Touch/Massage for Therapeutic Intervention .............................................................. 70 Nursing and Therapeutic Touch ......................................................... 70 Occupational Therapy and Sensory Integration ................................. 72 Other Touch Therapies ...................................................................... 74 Best Practices Among Practitioners in Early Intervention ............................ 78 Summary and Conclusions ............................................................................ 80 III. RESEARCH METHODOLOGY ................................................................... 82 Measures ........................................................................................................ 83 Participants ..................................................................................................... 86 Data Analysis ................................................................................................. 88 Summary ........................................................................................................ 91 IV. RESULTS ...................................................................................................... 94 Demographic Information .............................................................................. 95 Primary Study .................................................................................... 95 Pilot Study .......................................................................................... 98 x