A diet to control autism? Welcome to the GFCF diet

The autism spectrum disorders (Childhood autism, Aspergers Disease and Rett's syndrome) can take a huge toll on the caregiver and dentist alike. The energy and time spent in deling with a child with special health care needs can drain even the most patient of us. It is therefore the dream of every parent of an autistic child to be able to find a cure that will calm the child down, and the Gluetein free Casein free diet (GFCF) diet is supposed to do just that.

Historical Background

In the 1960s, Curtis Dohan speculated that the low incidence of schizophrenia in certain South Pacific Island societies was a result of a diet low in wheat and milk-based foods. Dohan proposed a genetic defect wherein individuals are incapable of completely metabolizing gluten andcasein as a possible etiology for schizophrenia. Dohan hypothesized that elevated peptide levels from this incomplete metabolism could be responsible for schizophrenic behaviors.

The possibility of a relationship between autism and the consumption of gluten and casein was first articulated by Kalle Reichelt in 1991.Based on studies showing correlation between autism and increased urinary peptide levels, Reichelt hypothesized that some of these peptides may have an opiate effect. This led to the development of the Opioid Excess Theory, expounded by Paul Shattock and others,which speculates that peptides with opioid activity cross into the bloodstream from the lumen of the intestine, and then into the brain. These peptides were speculated to arise from incomplete digestion of certain foods, in particular gluten from wheat and certain other cereals and from casein from milk and dairy produce. Further work confirmed opioid peptides such as casomorphines (from casein) and gluten exorphines andgliadorphin (from gluten) as possible suspects, due to their chemical similarity to opiates. Reichelt hypothesized that long term exposure to these opiate peptides may have effects on brain maturation and contribute to social awkwardness and isolation. On this basis, Reichelt and others have proposed a gluten-free casein-free (GFCF) diet for sufferers of autism to minimize the buildup of opiate .

Does it Work?

The opinion of the medical world is certainly divided on this issue. While several parents and institutions swear by the efficacy of the GFCF diet, many doctors have remained skeptical of it's efficacy. Research on the diet has been sketchy at best and there are no randomized control trials showing its efficacy. On the contrary it has been argued that the nature of children with autism makes any form of Randomized control difficult if not impossible, and that the positive reactions of thousands of parents cannot be dismissed lightly.

Is it safe?

Whether the diet works or not the far more imporntant issue is one of safety. The only way to implement the GFCF diet is to restrict the intake of milk and milk products in order to eliminate casien (which is a milk protein). Children with Autism have been known to have weaker bones and autistic children who were on GFCF diets have been shown to have significantly lower cortical bone thickness than autistic children who were not. Advocates of the diet aknowledge this fact but attribute it to the fact that a GFCF diet without alternate sources of protein is the problem and not the diet itself.

Implementation of the diet

As mentioned above the GFCF diet involves complete elimination of all sources of glutein such as wheat, rye and barley. The elimination of casien includes the elimination of milk and milk products such as cheese. Whey or curd, however, is said to be acceptable. The traditional Indian food of Curd Rice is therefore a perfect example of GFCF food. Extensive information regarding GFCF diets and their iplementation can be found at www.gfcfdiet.com/

In conclusion

DCSN recognizes the importance of reducing the levels of opiod peptides in autistic children, and acknowledges the ability of the GFCF diet in doing so. But the consquence of removing casien and glutein from the child's diet must be kept in mind and suitable alternatives must be given after discussion with the dietician and/ or the pediatrician.

Intellectual disability: New name for an old problem???

It is never easy for any one to deal with a child with mental retardation. It is hard for the child no doubt, but equally hard for the parent to come to terms with the fact, and harder still for the dentist to approach the subject with the parent. 

A blunt " Is your child normal?" is not only insulting to the parent and child alike but also; given the broad range of the term "normal" thoroughly unprofessional. 

One of the ways in which the profession has tried to circumvent this problem has been to come up with newer and more "socially correct" terms. But does this really help us understand the condition or does it simply complicate matters by presenting us with a confusing array of terms which mean little to most? In this series of posts DCSN takes a look at our understanding of intelligence, intellect and the various conditions which manifest with intellectual disability.

Definition

The evolution of the term

Intelligence and measuring intelligence

Conditions which manifest with intellectual disabilty

What is Intellectual disability?

Intellectual disability is a disability characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills. This disability originates before the age of 18.

The term intellectual disability covers the same population of individuals who were diagnosed previously with mental retardation in number, kind, level, type, and duration of the disability and the need of people with this disability for individualized services and supports. Furthermore, every individual who is or was eligible for a diagnosis of mental retardation is eligible for a diagnosis of intellectual disability.

What causes intellectual disability?

Intellectual Disability or mental retardation is an umbrella term which is seen in a wide variety of conditions. Strictly speaking the clinician should treat intellectual disability as clinical sign suggestive of an underlying pathology rather than as a disease in itself. Given below is a list of conditions that can lead to intellectual disability

Causes of intellectual disability

(from Bherman Et al (ed) Nelson's Textbook of Pediatrics)

Category	Type	Examples
Prenatal (causes before birth)	Chromosomal disorders	Downs syndrome*, Fragile X syndrome, Prader Wili syndrome, Klinefelters syndrome
	Single gene disorders	Inborn errors of metabolism, such asgalactosemia*, phenylketonuria*,mucopolysaccaridoses Hypothyroidism*, Tay- Sachs disease        Neuro-cutaneous syndromes such as tuberous     sclerosis, andneurofibromatosis Brain malformations such as geneticmicrocephaly, hydrocephalus and  myelo-meningocele* Other dysmorphic syndromes, such as Laurence  Moon Biedl syndrome
	Other conditions of genetic origin	Rubistein Tabi syndrome De Lange syndrome
	Adverse material / environmental influences	Deficiencies* , such as iodine deficiency and folic acid deficiency Severe malnutrition* in pregnancy Using substances * such as alcohol (maternal alcohol syndrome), nicotine, and cocaine during early pregnancy Exposure* to other harmful chemicals such as  pollutants, heavy metals,abortifacients, and harmful medications such as thalidomide,phenytoin and warfarin sodium in early pregnancy Maternal infections such as rubella*,syphillis*,    toxoplasmosis,cytomegalovirus and HIV       Others such as excessive exposure to radiation*, and Rh incompatibility*
Perinatal  (around the time of birth)	Third trimester ( late pregnancy)	Complications of pregnancy* Diseases* in mother such as heart and kidney  disease and diabetes Placental dysfunction
	Labour (during delivery)	Severe prematurity, very low birth weight, birth  asphyxia Difficult and/or complicated delivery*  Birth trauma*
	Neonatal (first four weeks of life)	Septicemia, severe jaundice*, hypoglycemia
Postnatal  (in infancy and childhood)		Brain infections such as tuberculosis, Japanese  encephalitis, and bacterial meningitis Head injury* Chronic lead exposure* Severe and prolonged malnutrition* Gross understimulation*

Autism - The disease and Implications for Dental Care

Dr Sharat Chandra Pani

Autism is a severe developmental disorder that affects the way a child sees and interacts with the rest of the world. It limits their ability to interact with others socially, in fact many autism suffers avoid human contact. Autism is part of a larger group of disorders called pervasive developmental disorders (PDD).

In 1911 a  Swiss psychiatrist Eugene Bleuler, coined the term Autism to describe pepole who had a difficulty in communication, he however was referring to adult schizophrenia. The term as we know it today is attributed to Leo Kanner, an American Psychiatrist, who in 1943 coined the term while studying children at Johns Hopkins University. He based his discovery on findings from 11 children he observed between 1938 and 1943. What he studied were children who had withdrawal from human contact as early as age one.Until the 1960’s Autism was thought to be a form of schizophrenia, a misdiagnosis that led many parents to blame themselves for the problem.  It has only been in the last few decades that the medical fraternity has truly  begun to understand Autism; so it is not surprising that a great deal of confusion exists, even among the medical fraternity about the diagnosis, treatment and dental management of children with autism.

In this series of Posts DCSN looks at Autism, it's causes, probable management strategies and useful tips for the parent who is anxious about taking the child to the dentist for the first time; and also the dentist who is probably equally anxious about treating a child with autism.

 Posts for parents

 Posts for Dentists

Diagnosing Autism  

What causes Autism?  

Is a child with Autism always mentally retarded?  

Preparing your Child for a vist to the Dentist 

Preparing yourself to treat an autistic child 

Autism in India - the challenges of misdiagnosis  

Autism in India - Support Centers in India

Diagnosing Autism

Autism Symptoms vary widely in severity, include impairment in social interaction, fixation on inanimate objects, inability to communicate normally, and resistance to changes in daily routine. Characteristic traits include lack of eye contact, repetition of words or phrases, unmotivated tantrums, inability to express needs verbally, and insensitivity to pain.

Behaviors may change over time. Autistic children often have other disorders of brain function; about two thirds are mentally retarded; over one quarter develop seizures. Symptoms of autism can begin immediately after birth, but often parents begin to notice them when the child is between 12 and 18 months old. This is the age at which most infants begin to use language and show interest in social activities. A diagnosis of autism is usually made when the child is between 2 and 3 years, but new research is looking at ways to diagnose children as young as 12 to 14 months. Children with Asperger syndrome (one of five developmental disorders that represent the autism spectrum) may be diagnosed later because they do not have the same language or communication problems children with autism exhibit early on.

Some Common Signs Exhibited by Autistic Children

Spinning	Repetitive behavior (perseverance)
No speech	Balancing, e.g. standing on a fence
Flapping hands	Behavior that is aggressive to others
Walking on tiptoes	Lack of interaction with other children
Lack of eye contact	Extreme dislike of touching certain textures
Self-injurious behavior	Desire to keep objects in a certain physical pattern
Lack of interest in toys	Desire to follow set patterns of behavior/Interaction
Dislike of being touched	Treating other people as if they were inanimate objects
Non-speech vocalizations	Delayed echolalia: repeating something heard at an earlier time
Preoccupation with hands	Confusion between the pronouns "I" and "You"
Lack of response to people	Echolalia: speech consisting of literally repeating something heard
Extreme dislike of certain foods	Either extremely passive behavior or extremely nervous, activebehavior
Delayed development of speech	When picked up, offering no "help" ("feels like lifting a sack of potatoes")
Extreme dislike of certain sounds	"Islets of competence", areas where the child has normal or even advanced competence. Typical examples include drawing skill, musical skill, arithmetic, calendar arithmetic, memory skills, perfect pitch

Etiology of Autism

There is no theory of the cause of autism which everyone has found convincing. There may be multiple causes. Thus we will review some of the proposed causes. Most researchers are absolutely convinced that the cause is biological rather than psychological. Bernard Rimland in his book Infantile Autism (1965) cited the following evidence for a biological genesis and against the idea that parents cause their children to be autistic:

1. MERCURY poisoning in a genetically predisposed child 
2. Some clearly autistic children are born to parents who do not fit the autistic parent personality pattern.
3. Parents who do fit the description of the supposedly pathogenic parent almost invariably have normal, non-autistic children.
4. With very few exceptions, the siblings of autistic children are normal.
5. Autistic children are behaviorally unusual "from the moment of birth."
6. There is a consistent ratio of three or four boys to one girl.
7. Virtually all cases of twins reported in the literature have been identical, with both twins afflicted.
8. Autism can occur or be closely simulated in children with known organic brain damage.
9. The symptomatology is highly unique and specific.
10. There is an absence of gradations of infantile autism which would create "blends" from normal to severely afflicted.

Autism and the Brain

Even though the precise cause of autism remains unknown the following areas of the brain have been implicated in autism

What Does Not cause Autism

 

Of the many supposed causes for Autism, the one that created the greatest stir when published was the supposed association with the MMR (measles, mumps, rubella) vaccine . When published in Lancet in 1998 the study created a flurry of lawsuits, with parents in the United States rushing to sue the drug companies that manufactured the vaccine. However later investigation showed that the lead author of the article had a conflict of interest. In 2004 the New York Times reported that 10 of the original 13 authors had retracted their claims. Ealier this year a case control study proved without doubt the absence of any link between autism and the MMR vaccine

Hornig M, Briese T, Buie T, Bauman ML, Lauwers G, et al. 2008 Lack of Association between Measles Virus Vaccine and Autism with Enteropathy: A Case-Control Study. PLoS ONE 3(9): e3140 doi:10.1371/journal.pone.0003140

Does Autism mean Mental Retardation?

Not all Children with autism are mentally retarded however, it is said that between 75% and 90% of all autistics are mentally retarded. To be diagnosed with mental retardation, one must generally show significant impairment in adaptive living skills and have an IQ under 70 as measured by a standardized IQ test. At the same time, advertisements by certain autism awareness sites proclaim that geniuses such as Albert Einstein, Isaac Newton and Thomas Edison may have had forms of Autism. In order to understand this seeming paradox and to help both parents and dentists keep realistic expectations from an autistic child it is important for us to understand the term "Autistic Spectrum" and the disorders classified under it.

At the same time that Leo Kanner described autism in American children, a German scientist, Dr. Hans Asperger, described a milder form of the disorder that became known as Asperger syndrome. Thus these two disorders were described and are today listed in the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (fourth edition, text revision) as two of the five pervasive developmental disorders (PDD), more often referred to today as autism spectrum disorders (ASD). All these disorders are characterized by varying degrees of impairment in communication skills, social interactions, and restricted, repetitive and stereotyped patterns of behavior.  

Disorders such as Aspergers syndrome may result in individuals who, in spite of their social awkwardness, may have an extraordinary intelligence in other fields such as numbers. However the sad truth is that most children diagnosed with childhood autism will have some form of mental impairment. This is even more so in India where the cases with milder forms of autism often go undiagnosed.

Irrespective of their IQ, patients with autism will have some difficulty in communication and therefore it is imperative that both the dentist and parent prepare themselves for a dental visit

See Also

Preparing your Child for a Dental Visit

Preparing to treat an autistic child

For a detailed description of childhood autism you can download the following booklet, put forward by the national institute of mental health.

Click Here