GFCF Diet in Children with Autism

Dear Melissa,
My 3 year old son was just diagnosed with Autism. In researching this diagnosis, I am finding numerous on-line parent groups discussing the benefits of a Gluten-Free/Casein-Free diet. Should I consider changing my son’s diet? 

This is a pretty hot button topic. Knowing this, I completed hours of research and reviewed piles of literature on the topic. So, let's begin by defining these odd sounding dietary items, gluten and casein. Gluten is a protein found in cereal grains. The gluten proteins found in wheat, barley and rye are problematic for people with celiac disease or gluten sensitivity. Casein on the other hand is a protein found in milk and cheese. In addition, many processed foods also contain wheat products, milk products, or both.

Check-out the pile of literature I have collected!

What is a Gluten-Free/Casein-Free (GFCF) Diet?
The benefit of a GFCF diet is based on the theory that children with Autism Spectrum Disorders (ASD) may have an allergy or particular sensitivity to foods containing gluten or casein. In this theory, children with Autism process peptides and proteins in foods containing gluten and casein differently than other people do. Hypothetically, removing these compounds from a child’s diet will help reduce the common symptoms of Autism, such as social withdrawal and repetitive behaviors.

Pros of a GFCF diet:

• Many parents report that their child had a decrease of Autism-related symptoms after placing him/her on a GFCF diet.
• In general, a GFCF diet is often an overall healthier diet than the diet a child typically eats. This diet tends to have reduced amounts of fast foods, processed foods, and overall “junk”.
• After much searching, I found several articles from Dr. Harumi Jyonouchi that link certain elimination diets to an improvement in gastrointestinal symptoms for children with ASD. She suggests eliminating dairy first (since it has the most commercially available substitutes) then soy, then gluten as the final elimination if necessary. (Note that she not only researches a GFCF diet, but the elimination of soy as well.) There are several links to these articles in the resource section below.

Cons of a GFCF diet:

• Children on the Autism Spectrum often have severely limited diets already. The American Academy of Pediatrics voices concerns that eliminating even more items from their diet can cause severe nutritional deficiencies, especially calcium, vitamin D, and iron. These deficiencies are of particular concern because they have been linked to sleep disturbances in children with ASD. These nutrients are also vital for bone development.
• Purchasing GFCF products can be more expensive and time consuming for parents to locate.
• Probably the most important con: The literature as a whole simply does not support a GFCF diet for children with ASD. In 2010, Pediatrics (the Journal for the American Academy of Pediatrics) published a consensus report: “The Evaluation, Diagnosis, and Treatment of Gastrointestinal Disorders in Individuals with ASD.” This report stated:
  1. Available research does not support the use of a casein-free diet, a gluten-free diet, or a combined gluten-free/casein-free (GFCF) diet as a primary treatment for individuals with ASDs.
  2. Many dietary modifications are believed to have a beneficial outcome, although placebo effects are likely to be high in this setting.  
  3. It should be noted that the 15^th author of the 27 authors on this paper was Dr. Harumi Jyonouchi mentioned above.  

My Personal Opinion: 
The literature does not currently support the use of a GFCF diet. And, in over a decade of practice working with dozens of children who have been on a GFCF diet, I have never observed a noticeable improvement that coincided with introducing a GFCF diet OR returning from a GFCF diet back to a non-restricted diet.

That said, if I had a child with moderate to severe Autism, I would probably give it a try. Why? Because, even though I am extremely science-minded and want only true peer-reviewed research studies for intervention, I do know that every child is different, and every child reacts differently to the world around him. AND, we are talking about food. Plain food. Not a non-FDA-approved supplement that my neighbor is trying to sell me. Just food. And, according to Paul A. Offit, MD, author of Autism’s False Prophets, the biggest concern with the GFCF diet is the lack of calcium and vitamin D in the child’s diet. So, as a parent, if I was able to make sure that my child was getting plenty of calcium from food (dark leafy greens, almonds, broccoli, oranges, white beans, salmon) and getting plenty of vitamin D from short sun exposures (ask your doctor), mushrooms, and supplementation, I would definitely try it.

However, and this is a very important point, I would definitely try it for a specific period of time, say 2-3 months. I would then stop the restricted diet for the same period of time, and see if there was a difference in behavior and GI distress. Even better, don’t tell your child’s teachers/therapists that you are doing these diet modifications, and see if they observe changes in your child’s behavior. This will help to eliminate the placebo effect. You might possibly see that your child is among the minority of individuals who is greatly affected by these proteins. However, it will also let you know if you are wasting your time, money, and stress levels, and need to focus your energy elsewhere.

Are you a parent of a child with ASD who has tried a GFCF diet? Did it work for you? Did it not? I would love to hear your stories! 

I have provided TONS of resources this week, so you can look at both sides of the issue. Happy researching!

Resources/Supplemental Articles
Brennan, D. (reviewer) Gluten-Free/Casein-Free Diets for Autism, (September 2015) WebMD.

Bortfeld, H., In Defense of the CGCFST Diet for Children with Autism, (Posted September 29, 2015), Talk About Curing Autism (TACA) Non-Profit Advocacy

Buie, T. The relationship of autism and gluten, (2013) Clinical Therapeutics Journal, Harvard Medical School. 35(5), 578-83.

Buie, T., Campbell, D. B., Fuchs, G. J., Gleen, T. F., . . . Winter, H. (2010) Evaluation, Diagnosis, and Treatment of Gastrointestinal Disorders in Individuals With ASDs: A Consensus Report, Pediatrics, American Academy of Pediatrics, vol. 125 no. Supplement 1 S1-S18.

How helpful is the casein-gluten-free diet? Autism Speaks Non-Profit Advocacy

Jyonouchi, H., Sun, S., and Itokazu, N., Innate immunity associated with inflammatory responses and cytokine production against common dietary proteins in patients with Autism Spectrum Disorders (2002), Neuropsychobiology, 46 (2), 76-84.

Wang, S., Gluten-free diet has no benefit for Children with Autism, Study Finds, (September 14, 2015), Wall Street Journal.

Aquatic Therapy Benefits

Dear Melissa,
I hear that TEAM just opened a new Aquatic Center. My child loves to swim! Would adding aquatic therapy be appropriate?

I know it is odd to think about a child swimming when it is still cool outside, but Children’s Therapy TEAM now has an indoor pool facility! We offer physical, occupational, and speech therapy at our new Aquatic Center in Bentonville, at 1500 SE 28^th Street. The center is approximately 10,000 square feet with 5 treatment rooms, a large gym area, and 2 pools, one large and one small.  The center also includes 2 large changing restrooms with showers. The large pool is zero entry, has a lift, and is set at a water temperature of 90 degrees. The small pool is set at a water temperature of 92 degrees. TEAM currently has 7 full/part time physical therapists at the center, 3 occupational therapists, and 4 speech-language pathologists. By March, PT will increase to 8 therapists, and OT will increase to 7.

While I personally keep my feet firmly on land, I interviewed Aquatic Center TEAM occupational therapist, Dana Tolle, for the scoop:

Melissa:  Who is most appropriate for aquatic therapy?
Dana:  The water provides good resistance, so the kiddo who struggles to meet strengthening and coordination goals on land is appropriate for pool therapy. The buoyancy of the water helps decrease the effect of gravity and allows the child to have more success with body weight movements and strengthening activities.

Melissa:  What do you like best about aquatic therapy?
Dana:  I like how much the kids enjoy being in the water. It is more motivating for them to complete almost any therapy activity since they are having fun in the pool! I also like that it provides a medium for our kids to participate in an activity just as their typically developing peers do. The pool provides an ideal amount of sensory input, but it also provides so much more than that. It provides a much gentler platform for kiddos to work on strength, coordination, and self-care goals.

Melissa:  What can you do in the pool that you can't do in traditional OT on land?
Dana:  The pool allows for better handling of kids. The kids who struggle to walk or weight-bear on land display better trunk control and movement in the water. The pool also provides constant sensory input and allows us to work on self-care skills in an appropriate and natural environment for children.

Melissa:  Do you have any additional comments to add?
Dana:  We have seen many successes in the pool.  Kids are doing a better job following directions, becoming more independent with dressing, gaining independence in walking, improving bilateral coordination skills, increasing safety awareness, and displaying overall improved strength. As therapists, we have enjoyed sharing in these successes with each and every child!

It is evident by Dana’s responses, that the kiddos love pool therapy, and the therapists love pool therapy.  However, you know me; I want the facts. Here are some studies on the topic

• In a study of 37 infants/toddlers (6-30 months of age), the aquatics therapy group demonstrated “significantly greater gains in functional mobility” than the control group, which received traditional, land-based therapy. (Pediatric Physical Therapy, 2007)
• In a 2006 article published in the Journal of Physical and Occupational Therapy for Pediatrics, a study was conducted using 18 children with autism. Clinicians found improved swimming skills, attention to task, muscle strength, balance, eye contact, and the ability to tolerate touch. The children with ASD also demonstrated improved safety awareness around water. This is a huge benefit, given that drowning is one of the leading causes of death among children with autism.

As you can see, the literature supports aquatic therapy with pediatric populations for not only physical gains, but social and safety gains as well. If you are interested in aquatic therapy for your child, give us a call!

For more specific information related to speech-language therapy in the pool my colleague, Carmen Shumpert, has written about the benefits of water-based speech therapy in her TEAM Therapist One-on-One piece, Aquatic Speech-Language Therapy? My Top 6 Reasons I say, "Yes!"

Resources:
The Effect of Aquatic Therapy on Functional Mobility of Infants and Toddlers in Early Intervention.  Pediatric Physical Therapy.  2007.

Clinicians’ Perceptions of the Benefits of Aquatic Therapy for Young Children with Autism.  Physical and Occupational Therapy in Pediatrics.  July, 2009

Indoor Activities for Active Kids

Hi Melissa,
We have friends who have an 8 year old boy coming to stay at our house in a couple of weeks. This will make 3 kids in the house. Since it is too cold right now to send them outside, what are some fun, indoor activities to do with them, so that we don’t all go stir-crazy?

When the weather is nice and sunny, it is so easy to simply show the kids the door and say, “Go play!” Even with our crazy, hot and humid summers here in Arkansas, you can still send them outside if you have a sprinkler or some water squirters. But what about winter activities? Personally, I love having activities to do with the kiddos, but I can't stand the cold. Movies are a good option, but they are so expensive, and it is also hard to find something that everyone can agree on. Here is a list of my favorite family activities in Northwest Arkansas to keep you and your kiddos occupied on a cold, winter day.

Indoor Activities for Kids in Northwest Arkansas

Crystal Bridges  We are so fortunate to have such a world-class, FREE museum here in Northwest Arkansas! I know that works of fine art and young children are often a risky combination, but take a quick stroll through the art exhibits, and head straight for the kids' section. They have puppet shows, hands-on arts and crafts, building projects, and more. It is a fantastic place to take kids of all ages! And, if the sun happens to come out and warm things up a bit, there are miles and miles of beautiful hiking trails to burn off a little extra energy. Check out their calendar for specific children’s activities coming up soon!

Scott Family Amazeum  Explore dinosaur skeletons, pretend you are one of the first pioneers to Arkansas, climb stories high in a tree house, be inspired in the art studio, mix science and sweet treats in the Hershey Lab, etc. The list goes on and on! My daughter’s favorite activity was pretending to be both a worker and a shopper at the simulated Wal-Mart Neighborhood Market. I had to drag her out of it after an hour of play in just that one section! While this fantastic children’s museum is not free, they do have several “Priceless Nights” this winter/spring where the museum is on a “pay as you wish” basis. Check their website for details.

Brick-by-Brick  My kiddos LOVE Legos! Our friends’ kids LOVE Legos. Therefore, we spend a lot of time at Brick-by-Brick. For a very reasonable hourly fee, your child (and you!) can pick out any of the facility's huge Lego sets and build away. For the younger child/toddler, they also have the larger Duplo Lego bricks, as well as some pretend play kitchens, etc. The best part is that nothing is for sale! Therefore, your child can spend the afternoon building the $50 Lego set, but won’t beg you to buy the Lego set. But wait, it gets better! On certain evenings/afternoons, you can even drop off children who are age 5 years and older, and then run a quick errand or get an afternoon snack at Apple Blossom Brewing Company and Restaurant, which is right next door. And if you have been dealing with loud children all day, you might just need an hour of “inside voice only” time!

The Jones Center  Public indoor swimming, public indoor ice skating, public indoor basketball courts… so many fun indooractivities! The whole family can get rid of cabin fever together! Looking for more of a long term activity than just getting out of the house for the day? Ask them about their classes for dance (for children and adults), fitness, gymnastics, ice skating, hockey, martial arts, swimming, and many more! Nominal fees apply for many activities so take a look at their website for further details.

Highrise  A huge gym with wall-to-wall trampolines, foam pits, balance beams, climbing walls, trapeze, and so much more… What could be more fun? My family recently found the joys of this fantastic facility, and loved it so much that we went back just a week later. Their prices are a bit higher than some of the other facilities that I have listed, but I loved how the whole family could have a blast and burn off some energy as well!

Gymnastic Joe's  Located in the Northwest Arkansas Mall, this gymnastics facility opens its doors for kiddos to bounce on inflatables, jump on trampolines, and crash into foam pits, all at very reasonable prices. Their website states that their “open gym” times are generally geared toward children ages 2-10 years of age.  So much fun!

Now that we have reviewed several fun, kid-friendly places in Northwest Arkansas, our own family has houseguests coming in a couple of weeks… Let me know if you have other ideas for children’s activities in Northwest Arkansas! share@childrenstherapyteam.com

Benefits of Outdoor Play

Dear Melissa,
From your perspective as a Pediatric Occupational Therapist, what is your take on children’s need for outdoor time?

Currently, the average American child spends only 30 minutes in unstructured outdoor play each day, and more than 7 hours per day in front of an electronic screen (NWF). These statistics should not be new to anyone, as we have heard similar stats cited from various sources throughout the past several years. I, personally, have ranted many times on the need to decrease screen time with our children and increase interactive play. However, for the sake of this article, let’s not discuss what you should decrease or avoid, but let’s create a sound argument for spending more time in the great outdoors!

The fact that playing outside has physical, social, emotional, and cognitive benefits for children (and adults!) is somewhat of a no-brainer. It’s kind of along the lines of eating vegetables. Our grandmas told us to do it, and we all know from experience that it just makes us feel better. However, I won’t rely purely on common sense to dictate that we should all play outside more. I have rounded up some pretty fantastic articles/research studies on the subject!

Benefits of Outdoor Play

My top 5 reasons children benefit from playing outside.

1. Improved physical fitness

• Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years. One-third of our children and adolescents were reported as obese in 2012. (CDC)
• Outdoor play creates opportunities for children to burn off energy, build strength and endurance, and helps a child to develop their powers of observation and their assessment of risk. (Healthyalberta.com)

2. Improved attention to task

• A study published in 2004 by the American Journal of Public Health, found that green, outdoor activities reduced the symptoms of ADHD significantly more than did activities conducted in other settings. This held true even when the children were engaging in similar activities, just in different settings.
• These benefits of activities conducted in “green settings” helped improve attention for both children with hyperactivity and those with decreased baseline levels of attention.

3. Improved vision

• A study looked at 2 groups of children of Chinese ethnicity, one group living in Sydney and the other group living in Singapore. The children in Sydney actually read more books per week, and did more total near-work activity, but they also spent much more time on outdoor activities (almost 14 hours per week vs. just 3 hours per week). The children of Sydney, who spent much more time outside, had only a 3% rate of nearsightedness, while the children of Singapore had a much higher rate at 29%. (JAMA)
• In Shanghai, 86% of high school students have nearsightedness (myopia). Higher incomes, urbanization, and the intense education system in which students are commonly studying until midnight every night, are thought to be contributing factors to this high rate of myopia. (NPR)

4. Improved mental health  

• Seasonal affective disorder (SAD) is a type of depression that’s related to the winter months, when people have less opportunity to go outside.
• One of the primary treatments for SAD is light therapy (photo therapy) to help mimic the natural sunlight one would receive from being outside.
• A Standford University study (2015) had participants walk either through a park or through an urban environment. The participants who walked through the park showed lower levels of blood flow to the parts of the brain associated with “rumination” which is the “pattern of thought focused on the negative of oneself.” Conclusively, participants who walked through the park had less negative thoughts about themselves than the urban walkers.

5. Increased Vitamin D levels 

• Vitamin D plays a vital role in the bone-building process by helping the body to absorb calcium.
• Vitamin D is also required for a healthy immune system.
• Additional research on adults suggests that getting enough vitamin D may help lower the chances of developing heart disease, certain cancers, and other serious diseases like diabetes.
• The current recommendation is that teens get 600 IU of vitamin D per day.  Most teens fall incredibly short of this recommendation.
• Many children and adults don’t get enough vitamin D, due to not eating enough foods rich in vitamin D and having darker skin color. (Darker skin tones do not absorb vitamin D from the sun as well as lighter skin tones.)
• Getting vitamin D from the sun is one of the easiest ways to obtain more vitamin D. And where is the sun… outside! Of course, everything should be balanced in moderation. Talk to your doctor about your personal balance requirements for the benefits of vitamin D from the sun vs. the harms of UV radiation. (healthykids.org)
• The shortened version for me on the sun debate is that sunshine feels great, and that sunburns feel awful! Use basic sun protection rules to avoid getting too much of a good thing!

So put down your smart phone, computer, or whatever else you are using to read this blog, grab your kiddos,  and go outside and play!

Resources:

Langfitt, F. (Narrator).(2015, February 20).  Why Is Nearsightedness Skyrocketing Among Chinese Youth? [Radio broadcast episode]. All Things Considered. Washington, DC: National Public Radio, Retrieved from www.npr.org.

Rose, K.A., Morgan, I.G., Smith, W., Burlutsky, G., Mitchell, P., & Seang-Mei, S., (2008). Myopia, Lifestyle, and Schooling in Students of Chinese Ethnicity in Singapore and Sydney. Arch Ophthalmol, 126 (4), 527-530, Retrieved from www.archopht.jamanetwork.com.

Outdoor Play Benefits, Head Start Body Start. Early Childhood Learning & Knowledge Center, Retrieved from https://eclkc.ohs.acf.hhs.gov/hslc.

Health Benefits. National Wildlife Foundation, Retrieved from www.nwf.org.

Benefits of Outdoor Play, Retrieved from  http://www.healthyalberta.com/729.htm.

Childhood Obesity Facts, (2015, August 27), Center for Disease Control, Retrieved from www.cdc.gov/healthyschools/obesity/facts.htm.

Kuo, F.E., Taylor, A.F., (2004, September), A Potential Natural Treatment for Attention-Deficit/Hyperactivity Disorder:  Evidence from a National Study, American Journal for Public Health,  94(9), 1580-1586, Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448497/

Gavin, M.L, (2014, February), Vitamin D, Teens Health from Nemours, Retrieved from http://kidshealth.org/teen/food_fitness/nutrition/vitamind.html#

Seasonal Affective Disorder, (2014, September 12), Mayo Clinic, Retrieved from www.mayoclinic.org/diseases-conditions/seasonal-affective-disorder/basics/definition/con-20021047

Goodstein, E. (2015, July). Standford University study says spending time in nature benefits mental health. USA Today, Retrieved from http://college.usatoday.com/2015/07/09/study-nature-good-for-mental-health/

Recess Critical for Learning

Dear Melissa,
I have seen an article all over Facebook about a school in Texas that has increased recess time for their youngest students and has seen great results. What are your thoughts?

I love offering my perspective on recess in my role as a Pediatric Occupational Therapist. My stance is an enthusiastic, YES! Schools need more recess time. Children need to move. In just a few short generations, we have changed the demands on our children from farm and factory work (moving) to sitting still in chairs for hours on end at the tender age of just 5 years old. NOT REALISTIC! Add to that the over use of “screen time” and less “outside play time”…don’t even get me started!

Recess Critical for Learning

So let me refocus my brain (as I sit here at my computer). I know that teachers and schools are under immense pressure to show better and better test scores each year. I get it. However, I contend that recess is actually critical for learning and that limiting recess is counterproductive to the learning process. But let’s, once again, look for the proof in the literature. We can all guess that more play time and less sitting time is important for a happier and healthier 5 year old, both mentally and physically, but where is the evidence?

Rising ADHD Diagnosis
Here is the proof that ADHD is on the rise

• Nation-wide there has been a rise in ADHD from 7.8% in 2003 to 9.5% in 2007 and 11% in 2011 (CDC).
• In Arkansas, over 11% of children are currently diagnosed with ADHD according to the CDC (2011-2012).

The Benefits of Exercise to Learning
While the studies below don’t directly address ADHD, they do offer evidence of the benefits of exercise. These benefits can impact learning and focus in the classroom. I contend that the benefits are so great that by increasing recess time we could decrease the rate of ADHD diagnosis in children.

• Mountain Elementary is one of 4 public schools in Fort Worth, TX that is boosting recess time by following a program created by Debbie Rhea, a Kinesiology professor at Texas Christian University. Rea created a school day structure modeled after the Finnish school system, which consistently scores at or near the top of international educational rankings. This program allows kindergarteners and first graders FOUR recess times of 15 minutes each per day. The teachers were skeptical at first but are now reporting that the children:
  1. Listen better
  2. Follow directions better
  3. Try to solve problems on their own instead of coming to the teacher
  4. Have fewer discipline issues
• The American Psychological Association (APA) offers the term “the exercise effect” to describe the fact that “usually within 5 minutes after moderate exercise, you get a mood-enhancement effect.”
• The APA reports on a study in which exercise was generally comparable to antidepressants for patients with major depression (Psychosomatic Medicine, 2007)
• The Journal of Preventing Chronic Disease (July 2010) detailed a study of five schools in the Independence Missouri School District. Three schools were assigned the ABC (Activity Bursts in the Classroom) for fitness program, and the other 2 schools served as controls. Students of the ABC program had several structured physical activity breaks which were led by teachers throughout the day. The results? In students who received the ABC intervention they found:
  1. Improved physical fitness
  2. Less medication used for asthma
  3. Less medication used for ADHD

But what does the pediatrician say?
In 2013, the American Academy of Pediatrics published a policy statement which stated:

• For “optimal cognitive processing” a child requires a period of interruption (break) after each period of concentration. And no, switching from one cognitive task to another cognitive task does NOT count as a break. The doctors even say so!
• Multiple studies have demonstrated that recess, whether performed indoors or outdoors, made children more attentive and more productive in the classroom. This benefit was seen even if the children spent much of this recess time socializing rather than exercising.
• Through play at recess, children learn valuable communication skills, including negotiation, cooperation, sharing, problem solving, coping skills, as well as perseverance and self control.
• Teachers/staff should encourage physically-active recess through structured games and/or offering safe playground equipment to stimulate free play.
• Schools should consider having recess before lunch rather than after, due to studies that show that this practice reduces food waste and improves student behavior.
• American schools have recess ranging from 20-60 minutes depending on district. However, it is well known (to doctors at least) that attention spans wane after 40-50 minutes of instruction. Therefore, breaks should be scheduled at regular intervals instead of 1 longer session in the day.

And, as an aside, don’t even get me started on what a bad idea it is to take away recess as a punishment! Make the kiddo do laps (walking, running, skipping, whatever). That is generally acceptable in my book. But, never, ever, ever, ever take away recess as a punishment. Any teacher who does this is just shooting him/herself in the foot for an afternoon of even worse disruptive behavior! Who wants that?

Are you a teacher/school administrator? How do you think added/more frequent recess times would affect your students’ performance? Give your input! share@childrenstherapyteam.com

Resources
ADHD Resource Center. (2016, January). American Academy of Child & Adolescent Psychiatry. Retrieved from www.aacap.org.

American Academy of Pediatrics. (2013). The Crucial Role of Recess in School. 131 (1) pp. 183-188. Retrieved www.pediatrics.aappublications.org.

Connolly, C. (Narrator). (2016, January 4). Turns out Monkey Bars and Kickball Might be Good for the Brain [Radio broadcast episode]. NPR Ed How Learning Happens. Washington, DC: National Public Radio, Retrieved from www.npr.org

Katz DL, Cushman D, Reynolds J, Njike V, Treu JA, Walker J, et al. (2010, July). Putting physical activity where it fits in the school day: preliminary results of the ABC (Activity Bursts in the Classroom) for Fitness Program. Preventing Chronic Disease, 7 (4), Retrieved from www.cdc.gov

Strauss, V. (2014, July 8). Why so many kids can’t sit still in school today. The Washington Post, Retrieved from www.washingtonpost.com.

Want kids to listen more and fidget less? Try more recess…this school did. [Video file]. (2016, January 8). Retrieved from www.today.com.

Weir, K. (2011, December). The Exercise Effect. Monitor on Psychology, 42 (11), p 48. Retrieved from www.apa.org.