this house believes

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OUR NEW SERIES AIMS TO DEVELOP YOUR SKILLS FOR CRITICAL APPRAISAL MAKING DECISIONS EVIDENCE BASED PRACTICE

Doctorate in Speech and Language Therapy (DSLT)

Are you an experienced SLT with a strong interest in research? keen to carry out a research project in your work environment? The new UCL Division of Psychology and Language Sciences is offering a doctoral programme for speech and language therapists who wish to carry out research. Students will be based in Chandler House and in an excellent environment for clinical practice research. Project supervisors are likely to come from one of four specialist research departments in the division: Language and Communication, Developmental Science, Speech, Hearing and Phonetic Sciences and Linguistics or from associated Research Centres (http://www.ucl.ac.uk/psychlangsci). The second intake of this new professional doctorate will be in September 2010. It is a four year part-time programme, with up to two days per week attendance in the first two years. By the end of the second year you will have completed a detailed project proposal, obtained ethics approval and written your literature review. The final two years focus entirely on your own project (with your supervisors). For further information about the programme, see http://www.ucl.ac.uk/lifesciencesfaculty/research-programmes/speech-language-therapy. Applications will need to be received by 31st January 2010 and interviews will be held in April. For information on admissions please contact Anna Casey (a.casey@ucl.ac.uk).

Rachel Harkawik and Paula Leslie examine the case for gluten and casein elimination diets for children with autism in relation to the impact on speech and language therapy - and find the evidence wanting.
This House Believes explained
In her teaching, Paula Leslie uses a debating idea from the British Medical Journal to get her students to critically review a controversial subject. By understanding the strengths and weaknesses of the arguments on both sides, the students are better prepared to develop their own views. Students are strictly limited in word count and number of references to foster concise and relevant writing. Their work is now being adapted for Speech & Language Therapy in Practice. The debating format means: the Proposition is required to prove its case, while the Opposition aims to show why the Proposition is wrong either side can interrupt with a point of information while the other side is speaking our authors reach a conclusion based on the evidence and readers can continue the floor debate via the Critical Friends process see www.speechmag.com/About/Friends.

PhD in the Division of Psychology and Language Sciences

The new Division of Psychology and Language Science is offering Ph.D. programmes in each of the 8 Research Departments (http://www.ucl.ac.uk/psychlangsci/research). Applicants with a degree in Psychology, Speech and Language Therapy or a related discipline are invited to apply. Collaborations often take place across Research Departments and with other Centres of Research within UCL (e.g. Institute of Child Health, The Ear Institute, Institute of Cognitive Neuroscience, Neurology). The strength and breadth of UCL's research environment provides a uniquely rich and stimulating environment for research training (http://www.grad.ucl.ac.uk). General information about research programmes can be found at http://www.ucl.ac.uk/lifesciences-faculty/ research-programmes/research-pals/ and information on applying for an MPhil/ PhD programme in our division can be found at http://www.ucl.ac.uk/lifesciencesfaculty/research-programmes/pals_research_generalinfo/. Applications to the Division for competitive funding awarded by UCL must arrive by 31st January in the year you wish to start.

The Catherine Renfrew Studentship for Doctoral Studies in Speech and Language Therapy
The studentship provides support for a Speech and Language Therapist, practicing in the UK or abroad, to pursue doctoral studies at UCL in any area of clinical practice. The successful applicant may enrol on either the DSLT or PhD programme. The studentship will cover UK fees. Additional financial support may be provided in order to facilitate research training and activity, according to individual need. Applications are especially encouraged from candidates whose research studies are based in the workplace, with the support of their employer. The award of the studentship is managed by a committee of senior staff representing SLT-based research at UCL. Applications should be sent to Stefanie Anyadi (s.anyadi@ucl.ac.uk) at the same time as applications for DSLT or PhD are submitted. Further enquiries may be addressed to the Chair of the committee Professor Jane Maxim (j.maxim@ucl.ac.uk). Rachel Paula

Rachel Harkawik is a clinical fellow in the medical speech-language pathology clinical doctoral program and clinical coordinator at the University of Pittsburgh, USA, e-mail reh52+@pitt.edu. Paula Leslie is Associate Professor, Communication Science and Disorders at the University of Pittsburgh, USA, e-mail pleslie@pitt.edu. Paula is also a specialist advisor in swallowing disorders for the Royal College of Speech & Language Therapists.

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this house believes

This House Believes in autism diets

The proposition case: More time for therapy
With the number of reported cases of autism on the rise the push to find a cause has intensified. As there are no conclusive findings, different interventions are used to try to reduce the deficits associated with autism. One approach of paediatricians and families is the removal of gluten and casein products from the childs diet. Both are naturally occurring proteins; gluten is found in food such as wheat and barley, while casein is in milk. Due to increasing media attention on diet modification both from ongoing research and celebrity endorsements (McCarthy, 2007) parents may consult speech and language therapists to determine if dietary changes would be beneficial. As a profession we should be ready to comment on this topic from an evidence based standpoint rather than based on weak anecdotes. Our role is limited to helping guide, educate and answer questions from parents on how these diets may impact on speech, language, and swallowing services. Our debate therefore considers the evidence for gluten and casein-free diets in relation to their potential effect on our service delivery.

Defining the topic

POINT OF INFORMATION: None of the 30 participants were randomised into dietary groups, and a control group was not used. Observed changes were reported by parental diary entries in which no steps to ensure validity or to control for parental bias were noted. Not all children showed the same improvements. No attempts were made to determine why some children appeared to benefit from dietary changes over others. A study by Whiteley et al. (1999) also observed changes in behaviours after 22 children were placed on a gluten-free diet. These were reported both by parental interview and seen on the Behavior Summarized Evaluation (BSE, Barthelemy et al., 1990) observation scores. The reported changes may allow for additional practice of targeted skills - and increased practice is needed when acquiring new skills. The Whiteley et al. (1999) study found that the children with autism had higher levels of peptides in their urine, which could be impacting on the central nervous system and causing the undesirable behaviours. The authors hypothesised that this was because they could not break down casein and gluten correctly; eliminating these proteins from their diet would reduce the peptide level and therefore the behaviours. POINT OF INFORMATION: A later publication by Shattock & Whiteley (2001, p.267) said, because of inaccuracies in published reports, other researchers (including us) have been unable to replicate the findings. In the same publication they also stated that using elimination diets as a source of intervention is largely unproven in terms of efficacy (p.269).

munication and interaction after intervention as compared to the control group who showed no changes in this parameter. In the 2002 study, the diet group had significant changes in non-verbal communication, eye contact, reaction when spoken to and language peculiarities. No comments about verbal language and receptive changes were reported. The results suggest that a gluten-free and casein-free diet can positively influence an autistic childs language abilities. Speech-language services will still be needed but changes to what can be worked on in therapy may occur. Aspects such as non-verbal language may not need as much attention and thus other areas of deficit may be addressed. Most influential may be the decreased resistance to communication and interaction. Like behavioural improvements, this may allow for more practice of skills in therapy. POINT OF INFORMATION: In both studies, 20 participants were paired according to autistic traits, IQ, age and severity to ensure equality of dietary and intervention groups. One member of each pair was randomly selected to be in the dietary group. The parents were aware which intervention group their child was in although the researcher who was conducting testing and interviewing was not. (Single blinding was chosen over double blinding due to ethical issues as reported by the authors.) Monitoring of diet compliance was not conducted, weakening the confidence the reader has in the reported results. Generalisation was also limited by the number of subjects and the length intervention was carried out for. It should be considered that placebo effects may have influenced the results, since information on changes in behaviour was gathered during interviewing of the childs parent.

Impact on outcomes

Often factors outside the control of speech and language therapists may have the largest impact on our therapy outcomes. We must consider the amount of time devoted to managing behavioural issues, such as lost attention, and how this may affect progress.

Impact on behaviour

Children with autism have a wide range of impairments that influence how therapy is performed. Nazni et al. (2008) examined the effects of elimination diets over a two month period on selected behaviours in autistic children. Findings indicate children placed on casein-free and / or gluten-free diets showed statistically significant improvements in attention, sleep, hyperactivity, and anxiety / compulsions. The improvements observed in the study may directly affect how therapy is conducted. With enhanced attention, decreased fatigue due to improved sleep, and reduced hyperactivity, the time devoted to the childs therapy goals may increase.

Impact on communication

The effect of a gluten-free and casein-free diet on communication in children with autism was investigated by a group in Norway. Linguistic abilities were studied consisting of non-verbal and verbal language, and expressive and receptive language (Knivsberg et al., 2002). In 2003, Knivsberg et al. then studied childrens abilities and their resistance to communication and interaction. Statistically significant improvements in the ability of the diet group to communicate and interact were shown compared to the control group. Eighty per cent of the diet group also had no resistance to com-

Summing up the case for the proposition

Gluten and casein-free diets have positive effects on some children with autism in regards to attention, sleep, hyperactivity and anxiety, and may decrease resistance to communication and interaction. These changes may have a positive, direct impact on how therapy is conducted.

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This house believes

The opposition case: Costs outweigh benefits

With restrictions to what can be eaten on gluten and casein-free diets, concerns about nutritional safety arise. Is there evidence that the benefits of elimination diets outweigh the costs of dietary restriction? search and stated the specific search strategy used. They concluded that diet placed extra financial cost and limitations on foods of choice for the affected family member and we could not recommend their use as a standard treatment on the basis of the limited data available (p.16). Both reviews reflect the lack of research on dietary restrictions.

Judgment:

The motion is defeated

The diagnosis of autism spectrum disorder is devastating. Though recent research is continuing to gain more insight about the cause(s) of this disorder, no cure has yet been discovered. As speech and language therapists we must remember that the parents of children with this disorder are in a fragile position. Families are trying to deal with the loss of the child whose future they had imagined, and to care for the child that they have. This child may be at the very mild end of the spectrum, or have challenging behaviour and learning disabilities. Parents may have other children as well and have to balance all these factors. They will be desperate for something that helps. Many of us have friends outside of our working lives who are in this situation - and it is hard watching them over the years trying to cope with it all. Nonetheless, our duty as professionals is to back rationale with evidence and be mindful of our professional boundaries. Although our role lies in helping these children with their speech, language, and swallowing needs, parents may call upon us for advice concerning nutrition and behavioural concerns. We need to be careful of commenting on areas managed by nutritionists and psychologists, and to be aware of the evidence and its quality. The studies cited look at the participants as a sample from the autistic population and not as individuals. Elimination diets may be beneficial for an individual with autism. Reviewing the literature on how modified diets may help behaviour, attention and so on, we can see the attraction - but the evidence is not robust. Balancing that against the potential damage from malnutrition, where we do have good evidence, leaves us unable to support the move to a restricted diet. We need to be able to talk this through with families and direct them to other professionals who are in a better place to advise. We should be aware of the promises made in the media and popular literature and address them, whilst respecting a scared family trying to do the best they can.

Nutritional risks

Elimination diets place major restrictions on the foods that can be eaten, and potentially affect the childs vitamin, protein, and mineral levels. Arnold et al. (2003) examined if a gluten and casein-free diet would impact on amino acid levels in autistic children. Results indicate that autistic children, both on restricted and non-restricted diets, had poor protein nutrition. Those children on restrictive diets had a greater number of deficient amino acids and overall poorer protein nutrition than children on no restrictions. The authors note poorer protein levels have the potential to place a childs developing brain at risk. This is particularly relevant when considering the age at which autism is identified, and how much brain development is still occurring. The authors also observed that parents often lack medical supervision when following these diets, increasing the risk of malnutrition. Point of information: Retrospective studies restrict the control of several variables and reduce the level of evidence of the work. The limited number of children in the restricted diet group (n=10) questions the generalisation of results. Due to the nature of the study, authors had to assume the dietary restrictions were followed, and that information written in the charts was valid.

Summing up the opposition case

Gluten and casein-free diets have potential negative effects on children with autism with the possibility of protein malnutrition. The current evidence to support the use of this diet is limited, has poor external validity, and does not give a clear indication of the benefits of dietary intervention.

Efficacy review

To summarise the evidence on dietary restriction, Christison & Ivany (2006) published a review on the efficacy of gluten and casein-free diets. Results indicated that the evidence was small and flawed (p.s168). Reviewed studies had small subject numbers, often lacked a control group, and had heterogeneous populations. The possibility of placebo effects was also noted due to the high demands of diet implementation. The authors concluded the evidence failed to clearly support or refute the use of restricted diets. Point of information: This review would be difficult to replicate based on the information given. Search terms and the criteria for article inclusion were omitted. Only two databases were used in the search, leaving possible research undiscovered. Similar conclusions were however found in a stronger systematic Cochrane review by Millward et al. (2004), which contained information on both the inclusion and exclusion criteria. The authors conducted a rigorous

Arnold, G., Hyman, S., Mooney, R. & Kirby, R. (2003) Plasma amino acids profiles in children with autism: Potential risk of nutritional deficiencies, Journal Autism And Developmental Disorders 33, pp.449-454. Barthelemy, C., Adrien, J.L., Tanguay, P. & Garreau, B. (1990) The Behaviour Summarized Evaluation: Validity and Reliability of a Scale for the Assessment of Autistic Behaviours, Journal of Autism and Developmental Disorders 20, pp. 189204. Christison, G. & Ivany, K. (2006) Elimination diets in autism spectrum disorders: Any wheat amidst the chaff?, Developmental And Behavioral Pediatrics 27, pp.s162-s171. Knivsberg, A.M., Reichelt, K.L., Hoien, T. & Nodland, M. (2002) A randomised, controlled study of dietary intervention in autistic syndromes, Nutritional Neurosciences 5, pp.251-261. Knivsberg, A.M., Reichelt, K.L., Hoien, T. & Nodland, M. (2003) Effects of dietary intervention on autistic behavior, Focus on Autism and Other Developmental Disabilities 18, pp.247-256. McCarthy, J. (2007) Louder than words: A mothers journey in healing autism. New York: Dutton Adult. Millward, C., Ferriter, M., Calver, S. & Connell-Jones, G. (2004) Gluten- and casein-free diets for autistic spectrum disorders. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD003498. DOI: 10.1002/14651858.CD003498.pub3. Nazni, P., Wesely, E. & Nishadevi, V. (2008) Impact of casein and gluten free dietary interventions on selected autistic children, Iranian Journal of Pediatrics 18, pp.244-250. Shattock, P. & Whiteley, P. (2001) How dietary intervention could ameliorate the symptoms of autism, The Pharmaceutical Journal 7, pp.267-269. Whiteley, P., Rodgers, J., Savery, D. & Shattock, P. (1999) A gluten-free diet as an intervention for autism and associated spectrum disorder: Preliminary findings, Autism 3, pp.45-65.

References

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