2012 Journal Tidbits - Autism

Here are some study findings from the Journal of Autism and Developmental Disorders - one of my favorite journals - that struck me as worth sharing. By the way, you have until Dec. 31st (2012) to browse this journal for free on line.

 1. Is picky eating due to sensory issues or due to food rigidity?
This article suggests that some picky eating problems are due entirely to rigidity in the child's food selection patterns. Treatment in this case is motivational. A child is told they will try a certain food. They are offered a choice of reinforcers (rewards). If they eat the food, they receive the reinforcer. They are also rewarded with accolades.  If they do not eat the food, they do not get the reinforcer.

When trying a new food, the authors followed a hierarchical pattern similar to Kay Toomey’s SOS Approach method:

1. Touches the food
2. Puts food to the lips,
3. Bites the food, bites
4. Puts in mouth but does not swallow
5. Chews but does not swallow
6. Swallows reluctantly
7. Accepts food without signs of displeasure.

After18 weeks, children were spontaneously requesting the new foods they had tried. The three children in the study, Ken, Robbie and Daniel accepted 5, 9 and 8 new foods respectively at the completion of the 22 week study.

Source: Koegel, R. L., Bharoocha, A. A., Ribnick, C. B.,Ribnick, R. C., Bucio, M. O., Fredeen, R. M., et al. (2012). Using individualizedreinforcers and hierarchical exposure to increase food flexibility in childrenwith autism spectrum. J Autism Dev Disord, 1574-1581.

  
2. What causes self-injurious behaviors in autism? The seven risk factors for self-injurious behaviors are 1) poor sensory processing, 2) low cognitive skills, 3) poor language / communication skills 4) poor social function, 5) age (18 mo. - 19 yrs.), 6) rigid behaviors and 7) gender. However, these factors account for just 29% of the self-injury cases seen, with sensory being the greatest factor of these (5-7%). The authors hypothesize that chronic pain and psychosocial factors may play a large factor in the remaining 71%. Clearly, there is more work to be done.

Source: Duerden, E. G., Szatmari, P., & Roberts, S. W.(2012). Toward a better understanding of self injurious behaviors in childrenand adolescents with autism specturm disorders. J Autism Dev Disord,2515-2518.

3. Is there a relationship between anxiety and repetitive behaviors? Yes, repetitive behaviors appear to be a cause of anxiety. "It is possible that, for some individuals, interventions focused on a reduction of behaviors, promoting flexibility and reducing repetitive play may consequently reduce anxiety." See the next article for more on this.

Source: Rodgers, J., Glod, M., Connolly, B., & McConachie,H. (2012). The relationship between anxiety and repetitive behaviors in autismspectrum disorder. J Autism Dev Disord, 2404-2409.

4. Are there interventions for quieting repetitive behaviors? Yes, if the child's behavior can consistently be triggered. For example, give a child with autism six cars, he will line them up. That behavior is triggerable and can be replaced with functional behavior. How about if the behavior is not triggerable? That's a harder problem. Not only do we not have interventions, we are not doing the research to look for them.

Sources:

1.  Boyd, B. A., McDonough, S. G., Rupp, B., Khan, F.,& Bodfish, J. W. (2011). Effects of a family-implemented treatment on therepetitive behaviors of children with autism. J Autism Dev Disorders,1330-1341.
2.  Boyd, B. A., McDonough, S. G., F., & Bodfish, J.W. (2012). Evidence-based behavioral interventions for repetitive behaviors in autism.J Autism Dev Disorders, 1236-1248.

5. Do children with autism also qualify for anxiety disorder? Yes, the diagnoses overlap often in children and young people (40-45%). Specifically, in children with high functioning autism, anxiety should be treated (medicine or stress reduction techniques) as a way of supporting other methods of increasing social skills.

Source: White, S. W., & Roberson-Nay, R. (2009). Anxiety, social deficits and loneliness in youth with autism spectrum disorders. J Autism and Dev Disord, 1006-1013.

Sensory Vs Behavior Approach

There is a bit of unnecessary tension between the fields of applied behavior analysis and sensory therapy. There needn't be. Both approaches have tons of research. Sometimes there is an overlap in the type of therapy one might consider for a given situation. Excellent! Both types of therapists can give a problem a "go". I am grateful to have colleagues to refer difficult cases to and am glad to help their clients, as well.

I've compiled, what I contend, are a list of truisms regarding the scope and overlap of these two types of therapies.

1. Yes, there is such a thing as sensory processing disorder. Yes, there is evidence. Do sensory interventions work? In many cases, yes. See the many, many papers written.

2. No, sensory techniques do not solve all sensory issues. Sometimes a child has developed negative habits and a behaviorist can provide the best therapy. In fact, for truly challenging problems, a behaviorist approach can be a God-send.

3. A behavior approach can be the therapy of choice for feeding problems - even those with textures and tastes. Why? Sometimes the child just needs to get past the weirdness of texture and tastes. There is a rule of 13 tastings. When a child tries a food (that they don't hate) 13 times, they acclimate to it. This is especially important for children who are at risk for failure-to-thrive due to feeding issues.

4. Using one of the BIG sensory therapies such as Therapressure™ (Wilbarger Protocol), sound therapy or a strictly followed sensory diet can change the life of a child with sensitivity (hyper-reactivity) to sensory input. These children suffer - we need to help them

5. "ABA"-based therapies have helped many children with autism to attend to lessons in a regular-education classroom. This can be a life-changer for a child.

6. Movement and other sensory-style breaks throughout the day help all children to attend better in class. This can help all children achieve higher grades.

7. New medical research is uncovering unusual issues in children with autism that affect their behavior. Treating a medical issue with sensory or aba-style therapies can be a waste of time.

That's the short list. What other things might you add?

"I'm Not Hungry"

At my book club last night, someone related the story of a friend whose child doesn't eat and so throughout the day, the mother chases the child through the house with food on a spoon saying, "Here, eat this! Eat this!". What a sad story. I've heard it before - a number of times, actually, from the different parents I speak with.

There are any number of reasons that a child will limit food intake. Today I'll focus on sense of hunger. In future blog entries, I'll discuss sensory and motor issues, gag reflex, as well as emotional and social causes.

Why would a child not feel hungry?
         1. We'll start with the obvious - he or she is snacking between meals and so does not get hungry. This is theoretically easy to fix. Limit the size and number of snacks. Space snacks carefully so that they are midway between meals and not too close to dinner.
         2.  She doesn't experience hunger, in other words, a medical issue and so a trip to the doctor is in order. An older child might be taught to eat certain portion sizes on a schedule. The portions sizes will have to be estimated for her age and body size and adjusted as necessary.
         3. He is on ADHD or other meds that cause decreased hunger. This is again reason to visit a doctor. It may be that using supplemental nutritional drinks such as PediaSure creates a workable solution. (But keep reading...)

         4. She is so consumed with her world (possibly due to autism) that she is not in touch with her body. Giving the child alerting activities (proprioception is always useful!) may help her to break free of that state. Once alert, she should show interest in food.

         5. He is so consumed with emotional issues that he is out of touch with himself. Have him take a second to check in with his stomach may solve the problem.

One such child I see in school missed lunch - he wasn't hungry. I saw him outside of his classroom in tears. His teacher, who had no clue about what was wrong was trying to keep him from meltdown. I noticed that the cafeteria workers had put all the food away and now the opportunity for eating had passed. I took a good guess at what had happened to him and brought him to my room.

Me: "Did you eat your lunch?

Jacob: "No, I'm not hungry."

Me: "Are you sure? I want you to feel the sensation in your stomach."

Within seconds, he asked if he could get his lunchtime meds from the office. We went there and passed the cafeteria. A worker found 2 boxes of Rice Crispies and a fruit cup. Jacob took his meds, and then wolfed down the food in record time.

The last three cases are really just this: the child needs to learn to check in with his/her body. This may involve some heavy work (play) -- especially with another person to help with attention -- to get grounded. Once done, the child may finally feel the need for food.

Food Chaining

I went to the Food Chaining workshop in Chicago last weekend put on by Cheryl Fraker and colleagues. She uses a fairly simple method of expanding a child's diet by slowly increasing the number of flavors and textures that the child will accept.

There are a number of rules for therapists and parents to follow.

1. All meals (3 meals and 2-3 snacks) are scheduled and limited. 15 minutes for a snack and 20-30 minutes for a meal.
2. Children are fed foods that they like along with the new foods, so there is always something "good" on the plate.
3. New foods are chosen based on a rating system.
4. The child rates new foods on a 1 to 10 scale going from "love it" to "I gagged".
5. Force feeding is not allowed. The child picks up the food and puts it in her mouth.
6. If a child acts out and does not eat, then she must stay in the room until mealtime is over. Then she is not offered food again until the next meal.

It's a reasonable arrangement. The choice of which new foods to try is determined in a fairly simple manner - but I won't try to repeat it here in this small blog entry, you can get their "Food Chaining" book and read about it.

The book and the workshop also cover food allergies, and medical issues related to feeding and nutrition.

Things I learned while looking up something else...

1. It takes 8 - 10 tries for an older child to accept a new food. (I'm assuming that that number is for typically developing children.)

2. A study found that babies are more inclined to eat veggies (green bean, for example) if the green beans are followed by a treat such as peaches. This is just proof of what every mother knows works.

3. Raisins are good for the teeth ... BUT ... they can be made into a yeast starter (and so feed yeast and yeast infections!). I continue to find sugar(s), fructose and glucose a mystery. Not to mention honey!

Food aversion story

Food aversion therapy is by no means an easy thing to do. Children don't want to eat the foods they don't like (go figure!). So, we trick them, soothe them, cajole them, reward them and somehow many of them try and then eat heartily foods that wouldn't touch previously.

Here is a recent success. Three mornings a week, I do food therapy during snacktime with two 8-9 year old boys in the school attached to our clinic. Billy eats very few fruits, but he likes crunchy foods. So every day, I bring in an apple or pear cut 2 slices and then deliberately crunch on one slice while I put the other near his mouth. He can't resist. He still grimaces at the apple, so I don't make him eat it, just crunch on it. He loves to do that. And once in a while, he will chew and swallow a bite (with surprise).

A month ago, I brought in tangerines. I put a slice on my tray and had the boys practice cutting the orange. To my surprise, Billy started mashing the orange with his finger playfully. I did so, too. We made a mess and giggled. Then I encouraged him to lick his finger. We played with oranges a few times that week and then went back to apples.

Last week, Billy's mom caught me in the hallway, "I just have to tell you what happened! I was on the phone in the kitchen, when Billy came in. He took an orange from a bowl of fruit, peeled it and then ate the whole thing! THEN, he went back, got another one and ate part of that, too."

Success with oranges is very sweet!

Trying the SCD Diet

I have a couple of clients who are in various stages of following the SCD - Simple Carbohydrate Diet, ala pecanbread.com. On this diet, one foregoes all gluten, most milk products, all starches and sugars. A few exceptions: aged cheeses. goat yogurt and honey. One boy's mother, Colleen, gave me a half-inch stack of written material about the diet. I immersed myself in it to the point of actually trying it out. I did so with little preparation (other than going shopping). A sane family (Colleen's, for example) spends several months getting ready for the switch by trying new foods and recipes and checking for food allergies.

The diet moves through stages. First there is a 2-3 day cleanout period in which just chicken, hamburger patties, 2 cooked fruits, very ripe bananas and 4 cooked vegetables are eaten. After that, one adds more cooked fruits and vegetables slowly and then eventually adds raw fruits, raw veggies, nut butters, nut flours, goat yogurt, aged cheese, etc.

I stayed on the diet for 3 days, before I was forced to cry uncle, first from symptoms of low blood sugar and then second from fear of gall bladder complaints from too much oil. Let me explain.

I ate lots of meat, veggies and fruit. However, nothing seemed to fill me up. (I heard that one mother lost 15 pounds in the first week or so.) I am not overweight. I was starving. I ate a banana (legal) as a snack, but became very light-headed. Later I took a nap. Low blood sugar in action. Alarmed, I searched the pecanbread web site and looked for a solution. Sure enough low blood sugar is a known complication, and bananas are known to cause "drunken" behaviors. I found advice to eat blacker bananas (in which the starch was already broken down) or get more oil-laden foods into my body such as avocados, nuts and peanuts. I decided that the bananas would still have too much sugar, and so opted for the second solution.

Avocados and nut butters/flours were not legal in my beginner's diet, but I followed the advice anyway. I made a quick batch of hazelnut flatbread and combined with some turkey bacon (my personal cure for all that ails me) I felt better. Now, however, my stomach felt oily. I began to wonder if my gall bladder could keep up with this. I realized that I, for one, could not follow the diet as it was meant to be followed. Not all bodies can do all things. I skipped ahead and tried foods from stages 3 & 4. I added nuts, cheese and peanuts to my diet. However, I continued to have low blood sugar symptoms.

I finally had to give up and eat a sweet potato to help provide some balance. I am now re-introducing foods back into my diet (but no gluten or casein for now!) to get a better understanding of what effect each has on energy levels, yeast levels, gas, stools, etc in my body. By eating starches, I won't get the same results that others will get - and in fact, I am defeating the purpose of the diet. But I hope to mimic enough of the experience to provide support to my clients. Presumably, their constitutions are better suited to the diet than mine is.