Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 51  |  Issue : 1  |  Page : 3-16

Yoga as a therapeutic tool in autism: A detailed review


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 Publication13-Jun-2019

Correspondence Address:
Ananda Balayogi Bhavanani
entre for Yoga Therapy, Education and Research, Sri Balaji Vidyapeeth, Pillayarkuppam, Puducherry - 607 402
India
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DOI: 10.4103/ym.ym_3_19

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  Abstract 


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 2019 Jul 15];51:3-16. Available from: http://www.ym-kdham.in/text.asp?2019/51/1/3/260361




  Introduction Top


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.

Aim

To review the efficacy of yoga on the following functions and behaviors among individuals with ASD:

  1. Musculoskeletal function
  2. Cardiovascular function
  3. Neurological function
  4. Behaviors.


Objectives

To review the role of yoga through the following parameters among children with ASD:.

  1. Musculoskeletal function : Handgrip strength
  2. Cardiovascular function : Heart rate and blood pressure (BP)
  3. Neurological function : Reaction time
  4. Behaviors : Sensory processing, motor execution, social interaction, communication, and cognition.



  Yoga as Intervention on Existing Studies in Autism Population Top


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

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Table 2: A summary of published clinical trials examining relevant durations of yoga intervention in individuals with ASD

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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

  1. Sensory processing dysfunction


    1. Emotional response
    2. Visual response
    3. Listening response
    4. Sensory issues to taste, touch and smell
    5. Imitation
    6. Fear
    7. Anxiety
    8. Aggressiveness.


  2. Motor execution deficits


    1. Gross motor skills
    2. Fine motor skills.


  3. Communication disorders


    1. Verbal and nonverbal communication
    2. Receptive language
    3. Expressive language.


  4. Cognition


    1. Body use
    2. Object use
    3. Restricted interest.


  5. Social interaction


    1. Relationships
    2. 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).

Impaired communication

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.

Impaired cognition

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 Top


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 Top


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.

Acknowledgments

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.[179]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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