Elimination Diets

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Capella University *

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Psychology

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Dec 6, 2023

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Controversial Treatments: Elimination Diets Treasure M. Jefferson Department of Social and Behavioral Sciences, Capella University PSY 7710: Ethics for Behavior Analysts Dr. Meredith Mates July 30th, 2023

2 Gluten- Free Casein- Free Diets Autism Spectrum Disorder (ASD) is a developmental impairment characterized by speech delays, restricted or repetitive behavior and interests, difficulty in social interactions and social communications, and other symptoms that differ from person to person (CDC, 2022). Because the expense of healthcare for people with autism is double that of their neurotypical counterparts, families and individuals explore alternative methods to help their cause (Marin et al., 2022). While the specific cause of symptoms is uncertain, several ideas have been proposed to explain ASD. For example, gluten-free casein-free diets (GFCF) eliminate foods containing gluten (a protein found in wheat, rye, and barley products) and casein (a protein found in dairy products) because research in the 1980s suggested they contributed to brain-altering functions (Baspinar & Yardimci, 2020). Those who campaigned for this stated that children with autism have "leaky guts" that enable opioids to escape into the bloodstream, travel to the brain, and induce autistic symptoms (Beware of Non-Evidence Based Treatments, 2023). Pros and Cons of GFCF Diets Pros of Gluten- free Casein- free Diets While there is no scientific evidence that this alternative is effective, studies have shown that if individuals had underlying food sensitivities and allergies, removing gluten and casein from their diets did reduce their gastrointestinal issues (Pennesi & Klein, 2012; Mar-Bauset et al., 2014; Elder et al., 2015; Hyman et al., 2016; & Ly et al., 2017). In one study, parents who eliminated all GF and/or CF foods reported that their children's ASD behaviors, physiological symptoms, and social behaviors improved more than children whose parents did not eliminate all GF and/or CF foods (Pennesi & Klein, 2012). While these studies suggest that removing gluten

3 and casein from the diet can benefit people with ASD, we must also consider the longevity we eliminate from these individuals' diets. Cons of Gluten- Free Casein- Free Diets There is a correlation between individuals with autism being picky with food consumption which can create other underlying health concerns (Garey, 2023). While the studies in the pro section show that if individuals already have gastrointestinal issues and food sensitives, restricted GFCF foods are beneficial, other studies show that if individuals do not experience these symptoms, they can trigger them. In one study, the systematic review reported that incorporating a GFCF diet may cause some increased incidence of gastrointestinal adverse effects; based on their reports, they surveyed parents who performed the diet in hopes of reducing or even eliminating autistic symptoms (Keller et al., 2021). Evaluation of Ethics Our clients and their caregivers are entitled to choose any intervention they want. However, as behavior analysts, we are aware of the restrictions that we have when it comes to giving reliable resources to our clients. Code 1.05 in the ethics books talks about practicing within our scope of competence, and with the GFCF diet, this is more of a nutritional problem, so I recommend that they seek medical advice for that. However, I could not dive into practices that might benefit my client because i'm not a medical practitioner (BACB, 2020). I can incorporate code 2.10, which I can collaborate with these medical practitioners to create an effective treatment plan that also falls along the scope of behavioral analytics and shows significance for my client's service (codes 2.14- 2.16). Effective Evaluation

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4 Evaluation treatments are used in ABA to assess the outcomes and impacts of behavior- analytic services for children with autism; as a result, program evaluation results can lead to the adoption of long-term strategies that increase quality, efficiency, and access to services (Miller, 2016). We use evaluation treatments to show the progress and the steps of orders we placed for our clients to determine if those treatments were beneficial or if we need to update the treatment that is more applicable for the client. For example, if we are helping a client with more adaptive skills like putting on clothes. We first need to identify the timeline for this goal, what the goal would be for the behavior to be considered a maintained behavior, and why this goal is essential for this client. When creating evaluation plans, we need to ensure that we are specific in these details so others can see objectively the importance of these goals. Communicating with Colleagues and Families As stated in the evaluation of ethics, I can work with a medical practitioner to guarantee that if the client wishes to work on that behavior, we can ensure that the intervention is done using behavioral analytic treatment. I understand that we cannot compel a child to eat something they do not like, but we can introduce them to known foods to show them other options. In one research, Valdimarsdóttir et al. (2010) employed differential reinforcement of alternative behavior (DRA), escape extinction, and stimulus fading to promote acceptance for their 5-year- old autistic client. They collaborated with parents to discover the child's chosen and non- preferred food items. Then they performed a preference assessment called paired choice to decide which food and toy reinforcers would be most effective during the intervention phase. When the non-liked food was offered, they would urge the child to eat only one bite before receiving a chosen edible or toy based on their motivation. I would recommend that with my

5 client as well, and if they did not want to eat it, I could adjust the programs to have them touch or sniff it first, then fade that prompt into taking a bite.

6 References Baspinar, B., & Yardimci, H. (2020). Gluten-Free Casein-Free Diet for Autism Spectrum Disorders: Can It Be Effective in Solving Behavioural and Gastrointestinal Problems? . The Eurasian journal of medicine, 52 (3), 292–297. https://doi.org/10.5152/eurasianjmed.2020.19230 Behavior Analyst Certification Board. (2020). Ethics code for behavior analysts. https://www.bacb.com/wp-content/uploads/2020/11/Ethics-Code-for-Behavior-Analysts- 210106.pdf Beware of Non-Evidence Based Treatments. (2023). Autism Science Foundation . https://autismsciencefoundation.org/beware-of-non-evidence-based-treatments/ Centers for Disease Control and Prevention (CDC). (2022). Autism Spectrum Disorder (ASD). National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention .https://www.cdc.gov/ncbddd/autism/signs.html. Elder, J. H., Kreider, C. M., Schaefer, N. M., & de Laosa, M. B. (2015). A review of gluten- and casein-free diets for treatment of autism: 2005-2015. Nutrition and dietary supplements, 7 , 87– 101. https://doi.org/10.2147/NDS.S74718 Garey, J. (2023). Autism and Picky Eating. Child Mind Institute . https://childmind.org/article/autism-and-picky-eating/

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7 Hyman, S. L., Stewart, P. A., Foley, J., Cain, U., Peck, R., Morris, D. D., Wang, H., & Smith, T. (2016). The Gluten-Free/Casein-Free Diet: A Double-Blind Challenge Trial in Children with Autism. Journal of autism and developmental disorders, 46 (1), 205–220. https://doi.org/10.1007/s10803-015-2564-9 Keller, A., Rimestad, M. L., Friis Rohde, J., Holm Petersen, B., Bruun Korfitsen, C., Tarp, S., Briciet Lauritsen, M., & Händel, M. N. (2021). The Effect of a Combined Gluten- and Casein- Free Diet on Children and Adolescents with Autism Spectrum Disorders: A Systematic Review and Meta-Analysis. Nutrients, 13 (2), 470. https://doi.org/10.3390/nu13020470 Ly, V., Bottelier, M., Hoekstra, P. J., Arias Vasquez, A., Buitelaar, J. K., & Rommelse, N. N. (2017). Elimination diets' efficacy and mechanisms in attention deficit hyperactivity disorder and autism spectrum disorder. European child & adolescent psychiatry, 26 (9), 1067–1079. https://doi.org/10.1007/s00787-017-0959-1 Marí-Bauset, S., Zazpe, I., Mari-Sanchis, A., Llopis-González, A., & Morales-Suárez-Varela, M. (2014). Evidence of the gluten-free and casein-free diet in autism spectrum disorders: a systematic review. Journal of child neurology, 29 (12), 1718–1727. https://doi.org/10.1177/0883073814531330 Matin, B. K., Byford, S., Soltani, S., Kazemi-Karyani, A., Atafar, Z., Zereshki, E., Soofi, M., Rezaei, S., Rakhshan, S. T., & Jahangiri, P. (2022). Contributing factors to healthcare costs in

8 individuals with autism spectrum disorder: a systematic review. BMC health services research, 22 (1), 604. https://doi.org/10.1186/s12913-022-07932-4 Miller K. L. (2016). The Use of Evaluation in Treatment Programs for Children with Autism. Behavior analysis in practice, 10 (1), 35–44. https://doi.org/10.1007/s40617-016-0130-3 Pennesi, C. M., & Klein, L. C. (2012). Effectiveness of the gluten-free, casein-free diet for children diagnosed with autism spectrum disorder: based on parental report. Nutritional neuroscience, 15 (2), 85–91. https://doi.org/10.1179/1476830512Y.0000000003 Valdimarsdóttir, H., Halldórsdóttir, L. Y., & Sigurthardóttir, Z. G. (2010). Increasing the variety of foods consumed by a picky eater: generalization of effects across caregivers and settings. Journal of applied behavior analysis, 43 (1), 101–105. https://doi.org/10.1901/jaba.2010.43-101

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