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Enhancing Interaction Through Positive Touch

E. Michelle Pardew and Carol Bunse
Young Exceptional Children 2005 8: 21
DOI: 10.1177/109625060500800203

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 E. Michelle Pardew, Ph.D.,
WesteCarol
rn Oregon UniBunse,
versity, and M.S.,
TeachingResarchInstiue,Monmuth,Or

Enhancing Interaction
Through Positive Touch
L uisa,
room
alively two-year old with autism, runs around the living
in her family home. She flits from one object to another,
first flipping the magazine on the table, then banging a toy on
the wall, and then quickly moving to bounce on the couch cush-
ion. Pilar, her mother, has spread toys out on the floor and peri-
odically calls to Luisa to join her in play. Finally, Pilar waits until
Lusia is nearby and then rubs her hands together saying, "Do
you want a massage, Luisa?" Luisa pauses and then comes over
to her mother and sits on her lap. After a few minutes of back
and shoulder massage, Luisa is visibly relaxed and is able to sit
on the floor with her mother and play with the toys for several
minutes. Luisa’s mother has built a form of massage called "pos-
itive touch" into Luisa’s daily routine.

Positive Touch and caregivers with simple and

Positive touch is an application of
positive ways to touch their child
that contribute to the overall goal
the ancient practice of infant of providing a nurturing environ-
massage. Infant massage typically ment that supports the child’s
incorporates a series of specific growth and development. That
strokes to the entire body, usually
in a time set aside as a massage
is, caregivers and family mem-
session. In contrast, positive
bers, such as Pilar in the vignette,
touch incorporates the massage
might use positive touch strate-
strokes into ongoing family rou-
gies to facilitate their child’s
tines rather than asking families
development of self-regulation
skills while simultaneously
to set aside dedicated time on a
enhancing the adult-child
regularly scheduled basis (e.g., relationship.
three 15-minute sessions at spe- Enhancement of the
cific times during each day as
caregiver-child relationship has
reported by Field et al., 1986). become increasingly important as
Positive touch provides families

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21
there are more infants and young
children who are at risk for devel-
opmental delays and other devel-
opmental disabilities due to
prematurity, low birth weight, and
negative physical or environmental
factors (Klaus, Kennel, & Klaus,
1996). Children in these circum-
stances often exhibit an aversion
to touch and therefore are less
likely to experience frequent and
consistent occurrences of positive
touch. This cycle of touch resis-
tance, caregiver avoidance, and
deprivation denies these children a
primary means for bonding with
caregivers. Reduced interactions
with caregivers can result in issues
of weak attachment and the pos-
sibility of permanent developmen-
tal and behavioral problems
(Brazelton, 1991; Calhoun &
Rose, 1991; Carmen, 1994; Klaus,
Kennel, & Klaus, 1996). Positive
touch is an experience that may
allow children to discover that
their caregivers are people they
can trust.
This article describes infant
massage techniques in the form of
positive touch strategies for fami-
lies and caregivers to practice in
their daily routines. First, how-
ever, a brief summary of the ef-
ficacy research on infant massage
for infants and young children in
general, and children with identi-
fied disabilities specifically, is pro-
vided. Suggestions for introducing
positive touch to families, illus-
trated by vignettes of families who
have adapted positive touch tech-
niques for their children with
autism, are also presented.
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22
Efficacy of Infant
Massage
Infant massage has been used for
centuries in some cultures as a reg-
ular part of child rearing
(Blackwell, 2000; Field, 2001;
Schneider, 1996). In one of the
earliest known medical texts from
India, the Ayur-Veda, massage is
listed as a primary healing practice
(Blackwell, 2000). In some cul-
tures massage is used to improve
circulation, treat muscular disor-
ders, and as a daily routine to pro-
mote calming of infants. The more
recent popularization of infant
massage in the United States is the
result of the efforts of individuals
such as McClure (2000) and organ-
izations that train infant massage
instructors, including the
International Association of Infant
Massage (n.d.) and the
International Loving Touch
Foundation (n.d.). Furthermore,
the popularity of infant massage
approaches may be driven by the
widely acknowledged importance
of early tactile and kinesthetic
stimulation for healthy neurologi-
cal development and for support-
ing the caregiver-child relationship
(Montague, 1986). _
During the last two decades
researchers have been measuring
the effects of positive touch on
infants, primarily when delivered
as massage, including an extensive
set of studies by Field and associ-
atesof the Touch Research
Institute (TRI, n.d.). The TRI, on
its Web site, reports having con-
ducted more than 90 studies on
the positive effects of massage
therapy on many functions and
medical conditions in varied age
groups. Among their reported sig-
nificant research findings are
enhanced growth (e.g., in preterm
infants); diminished pain (e.g.,
fibromyalgia); decreased autoim-
mune problems (e.g., increased
pulmonary function in asthma and
decreased glucose levels in dia-
betes) ; enhanced immune function
(e.g., increased natural killer cells
in HIV and cancer); and enhanced
alertness and performance (e.g.,
EEG pattern of alertness and bet-
ter performance on math
computations).
Specifically, an early research
study indicated that preterm
infants who received massage were
more alert and gained 47% more
weight than control group infants,
although both groups received the
same amount of food (Field et al.,
1986). The massaged infants were
better able to regulate their emo-
tional states and spent less time in
the hospital. Furthermore, positive
touch has been reported to pro-
vide for children’s inborn need for
physical contact and facilitate
motor development for infants
who are premature and delayed
(Calhoun & Rose, 1991; Drehobl
& Fuhr, 1991). It is interesting to
note that in earlier studies infant
massage was called &dquo;tactile kines-
thetic stimulation&dquo; to avoid pos-
sible negative connotations
associated with the word massage.
With the wide interest and accep-
tance that followed these early
studies, the terms infant massage
and, more recently, positive touch
have come into use.
TRI studies have addressed the
results of massage for children
Downloaded from yec.sagepub.com at Tumaini Uni-Ingringa University College on December 25, 2013
with a variety of disabilities
including attention deficit disorder
(Abrams, Field, & Hernandez-
Reif, in review); complications
from maternal depression (Pelaez-
Nogueras, Field, Hossain, &
Pickens, 1996); cerebral palsy
(Hernandez-Reif et al., in press);
and Down syndrome (Hernandez-
Reif et al., in review). Specific
applications to children with
autism have been reported to yield
improvement in attentiveness and
responsivity (Field et al., 1997)
and less stereotypic behavior and
sleep problems (Escalona, Field,
Singer-Strunck, Cullen, &
Hartshorn, 2001). Given the fact
that children with autism are often
very sensitive to touch, these
results are encouraging. Many
children with autism present sen-
sory issues and often calm to posi-
tive touch practices (Field, 2001).
Field suggests that &dquo;unlike random
touching in social situations, mas-
saging is predicable&dquo; (p. 134) and
children respond more positively
to touch when delivered with pre-
dictable, firm pressure. Field con-
cludes that the positive effects of
infant massage can only be main-
tained through a daily dose of
touch: &dquo;Touch is not only basic to
our species but the key to it&dquo;
(p. 135).
Despite these positive findings
from the studies of Field and col-
leagues (TRI, n.d.), there may still
be reason to proceed cautiously
with recommendations of use of
infant massage as a proven pri-
mary method for promoting men-
tal, motor, and/or social-emotional
development for young children
who are at risk for or have identi-
23

fied disabilities. Todate, three sys-
tematic reviews (i.e., Gallagher,
2003; Ottenbacher, Muller,
Brandt, Heintzelman, Hojem, &
Sharpe, 1987; Vickers, Ohlsson,
Lacy, & Horsley, 2004) of infant
massage techniques have been con-
ducted. Ottenbacher and his col-
leagues conducted a meta-analysis
in which they report that across
the 19 studies reviewed, study par-
ticipants performed better than
72% of the children in control
groups. However, they did
acknowledge that those studies,
which had design flaws, were also
those most likely to produce posi-
tive outcomes for the treatment
group. Both the Vickers et al.
(2004) and Gallagher (2003)
review concluded that while the
studies reviewed provided support
for infant massage, the credibility
of the findings across studies was
compromised by methodological
flaws. Gallagher concluded that
infant massage cannot be recom-
mended as an evidence-based
practice for positively affecting
cognitive, motor, or social-
emotional development in high
risk infants at this time. It is
important to note, however, that
none of the reviews indicated that
infant massage was an ineffective
intervention for young children
but rather that to date studies have
not been conducted in a manner
that adequately documents efficacy.
Alternately, it has been sug-
gested that infant massage/positive
touch techniques introduced to
families as a support or addition
to other early intervention may
have an additive positive impact
on young children with disabilities
Downloaded from yec.sagepub.com at Tumaini Uni-Ingringa University College on December 25, 2013
24
.
..
rese~t. ~,
ose is;~ illot
ooi to 10’
(Pardew, 1996). Caregivers often
.
,«.<,
n5~
P*’?[ t°
to
I° ?’ih6?’,giO&dquo;~gplJc~
fevilace YO’
v
,
experience frustration in interact-
vo~ yto . oeyttiovis
ing with their young children with
disabilities. For example, children 0i C,+°~’~~~~ t y .,Vey
with autism respond differently to
facial expressions; there may be a
time delay in their interactions or
other ty’~ to e~hdr~CLI,d vcrease
to ch~ld
YCLCtjolls
they may appear to be nonrespon-
sive. While using positive touch
(,,0 oyt.
the chy
caregivers can learn to closely
observe and interpret their child’s
interaction cues and adjust their
responses accordingly. Positive
touch builds confidence in the
developing relationship as the
caregiver learns an intervention
strategy that is done &dquo;with&dquo; the
child, not just &dquo;to&dquo; the child. As
noted by a mother of a preschool
child with autism, &dquo;Living with a
child with special needs was
uncharted territory for me.
Positive touch and massage
allowed me to get out of my head,
and opened up a new realm of
understanding and loving children.
I learned to communicate in new
ways&dquo; (Pardew, 1996).
Introducing Positive
Touch to Families
The primary purpose in presenting
positive touch is not to provide
therapy nor to replace other types
of interventions provided but to
enhance caregiver-child interac-
tions and increase the child’s com-
fort. The positive touch strategies
are delivered by the primary care-
giver and are usually taught in the
home in the context of daily rou-
tines. Children who are ill or have
chronic medical conditions should
be seen by a physician or therapist
to determine whether or not mas-
sage should be used, or if any
modifications in technique should
be made (Drehobl & Fuhr, 1991).
As home visitors teach positive
touch techniques to caregivers,
they should keep in mind the
following three components:
(1) focusing on building positive
interactions, (2) attending to
family preferences, and (3) using
positive touch in daily activities.
Building Positive description of each technique.
Interactions Effleurage and pressure touch can
both be used by a caregiver to
The professional demonstrates
calm and relax a child, while
positive touch primarily as a tech- kneading and milking strokes
nique to build positive interactions increase circulation and support
between caregiver and child. The
increased activity levels (Bunse &
fact that positive touch may have
other developmental benefits can Prevost, 2001). The home visitor
teaches these strokes using a baby
be considered a bonus. Certain
doll demonstrate while the
to
basic massage strokes are readily
adaptable for use by a caregiver caregiver practices with his or her
child. This teaching model allows
for achieving positive interactions
the caregiver to create competen-
with his or her child, including
cies and become the expert while
effleurage, pressure touch, knead- simultaneously building on his or
ing, and milking. Figure 1 pro- her relationship with the child.
vides both a graphic and written

Figure 1
Basic Massage Strokes

Source: 0 2002 by Teaching Research Institute, Monmouth, OR. Used with permission.

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25
 -4
leo,it, t~
c1’itBc
~ear~ tHe~~~g ~e,~.vey-
a~ ~5tec~~~~,es
’byli .
jiso
Gp,rGaye%’
eg;~~ers,-t~fI,e~’~5 ISO 1tvt As instruction continues, the
vr~~o to
’
t ~Se
~;ofl
*iS
w
o i t s e a toikcb ’
.
home visitor should place particu-
lar emphasis on the following
practices when introducing posi-
tive touch, as they play an impor-
tant role in building a positive
relationship between the child and
caregiver: (1) ask the child’s per-
mission, (2) make sure the child is
comfortable and relaxed, (3)
explain to the child what you are
doing with each positive touch
stroke, (4) incorporate songs and
nursery rhymes when appropriate,
and (5) read the child’s cues to
determine whether to continue
with positive touch during an
activity. Further, caregivers are
provided with strategies for learn-
ing to read their child’s verbal and
nonverbal cues (e.g., eye gaze,
movement, sounds) and to
respond appropriately, thus setting
the stage for more advanced
munication. Caregivers also learn
the critical importance of always
asking permission to use touch
techniques (McClure, 2000).
Surveyed caregivers reported that
asking permission enhanced their
respect for the child (Pardew,
1996). Permission seeking is par-
ticularly important for children
with disabilities who often have
fewer opportunities for making
choices than typical children.
Attending to Family
Preferences
The home visitor attends to social
and cultural perceptions of mas-
sage and touch by attending to
family preference for its use. Child
care practices often are dictated by
cultural traditions and caregivers
Downloaded from yec.sagepub.com at Tumaini Uni-Ingringa University College on December 25, 2013
26
who uncomfortable with a cer-
are
tain touch technique should not
feel guilty about omitting it.
Positive touch is a way to incorpor-
ate touch into the daily routines of
the child and family while honor-
ing the family’s cultural practices
and specific concerns. Consider
the following vignette.
Jacob, a three-year old with
autism from an abusive home
situation, has been placed with
Rhonda, a foster care provider.
Jacob has many tantrums and
seems lost in his new environ-
ment. Rhonda’s attempts to
comfort him by hugging him
and talking in a soothing man-
ner are not particularly suc-
cessful. Jacob’s home visitor
mentions positive touch and
Rhonda is interested, but feels
com- she could not possibly add
one more thing to her sched-
ule. She also states that she
feels a bit uncomfortable
about using touch with a child
who has been abused. The
home visitor describes several
basic touch techniques for the
hands, shoulders, or feet and
asks if Rhonda would be com-
fortable using any of these.
Rhonda indicates that touch
on the shoulders, arms, and
hands seems okay to her.
They then discuss the times of
theday when positive touch
might be helpful to Jacob and
will also work within Rhonda’s
schedule. For example, putting
on Jacob’s coat to go to
preschool almost always
results in a tantrum, even
 , 0
0 0.0. ~&dquo;, BA s’1%~
1bey, ,eg~~e~s
4$h6&dquo; , ,Ve,f b~0.~t~’Ve,
, BAsi1B’l, ~si iU ~ io8C~0

t ot1Be&eth; ~,~, ,,~1Bbe’l,i1B t

1’oBAti1Bes
s t1’~tec& orno1’¡,o. I1te tB1et1B &eth;i1BtO~i’
they Using Positive Touch in positive touch activities is when the
Daily Activities child is relaxed and alert. When

5~,tC,of ate
O 0&dquo;%b o t tb e
day. °

When caregivers become accus-

tomed to using positive touch
positive touch is familiar to the
child, it may be used during teach-
tB11’oBA~ strategies, they can begin to incor-
able moments throughout the day.
For example, when dressing a baby,
porate them into routines through- the caregiver can use the opportu-
out the day. For example, a hand or
when Rhonda shows Jacob his back massage can be given during nity to make eye contact and gently
picture schedule. Rhonda stretch the baby’s arms and legs. An
bath time, while watching televi-
arm or shoulder massage might be
agrees that firm pressure on sion, or while waiting in the doc-
Jacob’s shoulders and a few welcome to a preschool child to
tor’s office. Table 1 provides some
strokes down his arms prior to relax his or her muscles after a busy
examples of ways that positive
assisting him with his coat touch can be incorporated naturally day at school. The following
might help Jacob relax and into a child and caregiver’s daily vignette illustrates how to modify
prepare him for the transition. routine. Keep in mind that tech- positive touch strategies as the child
The home visitor demon- grows and develops to ensure that
strates the strokes on a baby
niques must fit individual family the strategies are developmentally
needs. The best time to introduce
doll she has brought along and appropriate.
then Rhonda tries. When
Rhonda feels comfortable with
the technique, she tries it with
Jacob. Table 1

The next week, Rhonda Examples of Ways to Incorporate

Positive Touch Into Daily Routines
reports some improvement
but indicates that Jacob is
often startled when she
touches his shoulders to begin
the routine. The home visitor
reviews the touch guidelines
and determines that Rhonda
has omitted asking permission
to touch Jacob. Rhonda states,
&dquo;This is part of our routine, it
seems silly to ask permission
first.&dquo; The home visitor notes
that getting permission to
touch not only alerts Jacob to
what is happening, but gives
him a choice about what he
wants. Rhonda tries for
another week, making sure
she asks for Jacob’s permis-
sion. She reports considerable
improvement in his response
to transitions. Note: For information Bunse and Prevost
more see (2001) video and guidebook.

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27
Pilar began using massage
during daily routines when her
daughter, Luisa, was 11I
months old and diagnosed
with autism. As she prepared
to dress Luisa, she often incor-
porated positive touch into the
routine. With Luisa on the
changing table wrapped in
blanket (i.e., the child in a
warm, comfortable position),
she would look into Luisa’s
eyes, rub her hands together,
and say, &dquo;Shall I rub your
feet?&dquo; (i.e., asking permission).
She would then look at Luisa
expectantly and wait until she
saw her squirm (i.e., paying
attention to the child’s cues
and giving adequate time to
respond). After observing that
Luisa was calm and alert, Pilar
would begin using effleurage
(see Figure 1 ) to stroke her
feet with firm, gentle pressure.
When she reached Luisa’s
0 tors can use with caregivers. After
s
all0tv
to
t0~
~~’B~YOvtl
to~,cH bed
,~ot a
1’osv . ies ~ Wto th e~,o~p.
· tive touch practices with a focus
~<-~
~.~<~
~ ~0~~B~~’ ~’ri
01
the
ca~
b otH
28
toes, she used her thumb and Conclusion
index finger in a gentle, back
Too often families who have chil-
and forth rolling motion on
dren with special needs are over-
each toe reciting &dquo;This little
whelmed with interventions that
piggy went to market&dquo; (i.e., intrude on family routines and
incorporating nursery rhymes
or songs). She would finish by highlight problems their child
kissing Luisa’s foot, putting on
might be experiencing. Positive
touch techniques allow families to
a her sock, and saying, &dquo;socks
embed a potentially beneficial
on.&dquo;
practice into their routines that
As Luisa became more mobile, supports the development of lov-
she was not willing to sit or lay ing connections for both the care-
still for any length of time. giver and child. Professionals
Pilar had to consciously seek serving as home visitors can
out teachable moments to receive training on how to instruct
incorporate a few massage caregivers to use infant massage
strokes and keep the positive from organizations such as the
touch connection through International Association of Infant
Luisa’s &dquo;wiggly&dquo; phase. Massage (n.d.) and the
Therefore, she modified her International Loving Touch
Foundation (n.d.). McClure
approach and would rub
Luisa’s back while she was (2000) provides a comprehensive
watching her favorite video guide to massage including Web
tape and would stroke her face site resources. Sinclair (1994)
at bedtime. offers a comprehensive handbook
of massage for children of all ages,
including children with special
needs. Bunse and Prevost (2001)
provide a videotape introduction
to positive touch that home visi-
investing in their own training,
home visitors can then introduce
YO~
the massage techniques and posi-
on caregiver-child interactions.
Of
Families and professionals who
work collaboratively to apply posi-
tive touch within the family rou-
tine provide &dquo;value-added
’
benefits&dquo; (Sandall, McLean, &
Smith, 2000). Beyond the physical
and emotional benefits, positive
touch truly allows families to com-
municate in new ways.
Downloaded from yec.sagepub.com at Tumaini Uni-Ingringa University College on December 25, 2013
Note
You can reach E. Michelle Pardew by e-mail at
pardewm@wou.edu
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