Dissertation

Louisa Pielichaty 200624294
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University of Leeds
SCHOOL OF EDUCATION
Online Submission of Assessed Work
Student Name Louisa Pielichaty
Student ID number 200624294
Degree programme Childhood Studies
Module code EDUC 3805
Module title Dissertation
Dissertation Title The Effects of Dietary Intervention on Children with Autism: A
Case Study.
Dissertation
supervisor
Mary Chambers
Word count 10991

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The Effects of Dietary Intervention
on Children with Autism: A Case
Study.
LOUISA PIELICHATY
STUDENT NUMBER: 200624294
MODULE CODE: EDUC3805- DISSERTATION
WORD COUNT: 10991
DISSERTATION SUPERVISOR: MARY CHAMBERS
FRIDAY 16TH MAY 2014

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Acknowledgements
I must start by acknowledging the special school at which I conducted my research
for this body of work and thank you for allowing me to come into your school and
complete my observations. In particular I would like to thank the Head Teacher for
taking the time to meet with me and provide me with some excellent contextual
information. I would also like to thank the other staff at this school, including the
catering staff who were so helpful in providing information regarding school meals
and showing me how the catering services work. I am so grateful to the teaching
assistants who took the time to complete the requested food diaries. I must also
thank the parent who returned the 7 day food diary, your input provided a new
dimension to the findings.
I extend my thanks to the 3 parents who returned the questionnaires I sent out.
Unfortunately due to the limited amount of returned questionnaires the results had to
be discarded, however the results of these questionnaires were used to inform my
research and provide relevant contextual information for me as a researcher.
I particularly owe thanks to the parents of Child X for not only allowing me to create a
case study on their son but for also being so helpful and forthcoming in the collation
of the case study details. Your help has been invaluable and I thank you for all the
time you have given me in replying to my questions and meeting with me.
I give huge thanks to my dissertation supervisor Mary Chambers for her constant
support and help throughout my studies. She has been my first port of call whenever
I’ve needed help and her guidance has been so reassuring. I would not have had
such a clear direction in my writing had it not been for Mary. Thank you to the other
members or staff at the School of Education who have also had to deal with my
panics.

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Special thanks goes to my family and friends for supporting me through all my
research and making this difficult task that little bit more enjoyable.
Finally I would like to thank all the children who were observed as part of my
research and all those who were indirectly involved.

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Contents Page
Abstract……………………………………………………………………………….7
Introduction…………………………………………………………………………..8
1.0Literature Review………………………………………………………………10
1.1Treatment……………………………………………………………….10
1.2Dietary Intervention…………………………………………………….11
1.3Gluten and Casein Free Diets………………………………………..13
1.4Opioid-Excess Theory…………………………………………………15
1.5Biomedical Approach………………………………………………….17
1.6Defeat Autism Now! …………………………………………………...18
1.7Nutritional Standards…………………………………………………..19
1.8Carbohydrates and Candida………………………………………….21
2.0Methodology……………………………………………………………………24
2.1Participants……………………………………………………………..24
2.2Research Methods……………………………………………………..25
2.3Research Instruments………………………………………………….27
2.4Ethical Issues……………………………………………………….…..29
3.0 Presentation and Analysis of Findings………………………………………33
3.1Observational Research Results……………………………………..33
3.2Carbohydrates………………………………………………………….35
3.3Food Diaries…………………………………………………………….36
3.4School Lunch 4 Week Menu…………………………………………..37
3.5Case Study……………………………………………………………...38
3.6Results of Nutrient Supplementation and Dietary Intervention……44

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3.7Average Financial Costs of Treatment………………………………45
4.0 Discussion of Findings………………………………………………………..46
4.1Carbohydrates………………………………………………………….46
4.2Connection to Gluten-free Dietary Intervention……………………..49
4.3Connection to Casein-free Dietary Intervention…………………….50
4.4Case Study……………………………………………………………...51
4.5Speech and Language Development……………………..………….51
4.6Cognitive Development and Motor Skills…………………………….52
4.7Limitations……………………………………………………………….53
5.0 Conclusion……………………………………………………………………..54
6.0 References……………………………………………………………………..57
7.0 Appendices……………………………………………………………………..63

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Abstract
The purpose of this dissertation is to investigate the link between dietary
interventions and children on the Autistic Spectrum. Through observational research
and the completion of food diaries, the researcher looked at the types of foods
consumed by a sample of children with autism both in a school and a home setting.
Results of this research were compared against findings from a review of literature in
the field of dietary and biomedical interventions. The prevalence of carbohydrate was
a prominent finding in the research, with subsequent detrimental effects on children
with autism discussed in regard to current research. The inclusion of a case study on
a 5 year old boy with autism currently undergoing a dietary intervention provides a
first-hand account of the possible benefits of such intervention. In his case, a gluten
and lactose free diet coupled with nutritional supplement and organic produce has
seen vast improvements on his behavioural, social and emotional development.
Whilst the results of this case study highlight the positive impacts of dietary
intervention on children with autism, further research is imperative to gain a greater
understanding of this relationship as there is a lack of evidence in this field.

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Introduction
The focus of this body of work was to research the use of dietary interventions for
children with autism; looking at the popularity of such interventions and examples of
biomedical approaches. The prevalence of autism in today’s society is more than 1
in 100 people, with 1.1% of the UK population thought to be on the autistic spectrum
(The National Autistic Society, 2014). Taylor et al, 2013, studied the prevalence of
autism in the UK of children aged 8 between 2004 and 2010. Results found that
during the 1990s, the annual incidence rates of autism increased “fivefold”, before
reaching “a plateau in the early 2000s” (Taylor et al, 2013, page 1). Whilst the
prevalence of autism is high, the awareness of dietary interventions and biomedical
approaches to ‘treating’ autism is not as widely circulated. This lack of awareness
provided the main contextual factor for the research conducted within this body of
work. There was also a personal vested interest in this subject; the researcher has
worked in the field of autism for over half a decade, and therefore much of the
information gathered was relatable to the researcher’s own experience.
The literature review section explores the vast scope of ‘treatment’ available for
children with autism, with particular reference to biomedical and dietary approaches.
The term ‘treatment’ is so highlighted as some people argue that autism is not a
disease as such that needs ‘treatment’, but rather a disorder that needs
‘intervention’. The reader is therefore left to make his/her own mind up vis-à-vis the
proper use of the word ‘treatment’. Gluten and casein-free diets feature throughout
the literature review and the high level of gluten intake in children with autism is an
ongoing theme running throughout this work.

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The inclusion of a case study adds another dimension to this study as it provides
primary data in terms of the effects of dietary intervention on a young boy with
autism. The information for the case study was gathered first hand by the researcher
and backed up by face to face contact with the child, known in this study as Child-X.
Further research has been used to inform this study; the researcher conducted
observational research in a special school and food diaries were also obtained. All
data bar the food diaries was collected by the researcher first-hand; the food diaries
were collated by each participant’s teaching assistant. Each aspect of the research is
included in the presentation and analysis of findings section and the appendices and
further evaluated in the discussion section. The overall focus of the study looks at
the observational research results and the case study and links both to dietary
interventions and the effects of certain food products on the body of a child with
autism. This body of work aims to provide an informative and explorative study into
the effects of diet and dietary intervention on a child with autism and to increase
awareness of such ‘treatments’.

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Chapter_1.0
Literature Review
1.1) Treatment
There are numerous therapies and treatments available for children with autism
which vary hugely in their approaches. The variety of approaches can be attributed
to the vast differences and effects treatments have on individuals, as well as
financial and social factors, including the availability of trained and knowledgeable
professionals to deliver treatments or therapies. Green et al, 2006, conducted
research into the plethora of treatments available to establish their typical use and
popularity. They published a study in which they surveyed 552 families of children
with autism, questioning them on their use of different treatments. Overall there were
111 different treatments recorded as used. Green et al 2006 found that on average
“families were using seven treatments at the time they answered the survey, with
one parent employing 47 treatments simultaneously” (Green et al 2006, page 962).
This shows the vast scope of treatments and also suggests that many families are
willing to try more than one treatment for their child. The anomalous result of 47
treatments, whilst an isolated case, provides an interesting platform for further
exploration into why this particular parent needed to use such a large number of
treatments. However Hess et al 2007 record no evidence of this having been
questioned and therefore the article accepts this result as simply anomalous.

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There is a lack of supporting information to explain the reasons why the families in
this study used their individual number of treatments. This is a clear weakness of the
study as this contextual information would have provided a greater understanding of
parental considerations of treatments. It would have added value to findings; offering
parental opinions on treatments and thus a deeper analysis of causal links between
each child and their parents’ chosen treatments. Results of this study do show that
speech therapy was the most common form of therapy. However Lee 2011
conducted research which disputes the popularity of speech therapy through her
contradictory results. Lee gained feedback from 14 parents/carers of children with
autism on their children’s use of Complementary and Alternative Medicines (CAMs).
The study reported “dietary-based therapies to have been the most common form of
CAM used by the parents for their children with ASD” (Lee, 2011, page 4). The vast
range of 111 treatments recorded in Green et al’s study reflects diversity across
families of autistic children. This review focuses on the effect that dietary and
biomedical treatment can have on children with autism.
1.2) Dietary Intervention
Dietary interventions or diet modification are classed under a group of treatments
known as CAM; (Complementary and Alternative Medicine). CAMs are often used to
“ameliorate the range of theorised biochemical abnormalities” (Angley et al. 2007
page 827) of children with Autistic Spectrum Disorder. They provide a form of
treatment that you would not find in mainstream healthcare. The categorisation of
CAMs covers a number of other treatments such as auditory integration therapy and
craniosacral therapy. In a study conducted by Hanson et al 2006, parents of autistic

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children were surveyed to determine the different types of CAM used to ‘treat’ their
children and the parents’ beliefs surrounding these interventions. The study group
consisted of 112 parents of children who were diagnosed with ASD between 1997
and 2003 and were patients of the Developmental Medicine Centre in Boston, USA.
Parents were questioned on numerous factors including their demographic and their
use of CAM. Similarities can be drawn with the aforementioned Green et al 2006
study which surveyed parental use of treatments for children with autism, not
specifically CAMs.
Overall, the findings of the research concluded that 74% of the families involved “had
used interventions categorised by this study as CAM” (Hanson et al, 2006, page
631). Of the 112 parents, 43% recorded a use of diet modification as a biologically
based therapy. These statistics highlight the popularity of biological therapies, yet the
study shows that conventional therapies such as educational and sensory therapies
are still the most widely used by parents. This contradicts Green et al’s results, who
found that speech therapy was the most popular treatment. 94% of the parents
involved in this study reported that they had used conventional therapies, which
includes prescription drugs. According to Hanson et al’s 2006 findings, this form of
therapy was given high rates in terms of usefulness and efficacy yet there is no
explanation as to why they were approved so highly. However the discussion of this
study reveals contradicting results in terms of the issues parents considered when
selecting their therapy. Most families were concerned about “unacceptable side
effects with prescription medication” (Hanson et al, 2006, page 633) and the safety
of this medicine. This contradiction suggests issues with the reliability of this study.

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The next section will look further into the dietary interventions and diet modification
treatments available for autistic children.
1.3) Gluten and Casein Free Diets
An example of a dietary intervention for children with autism is the gluten/ casein free
diet (GF/CF diet). Gluten is a combination of proteins found commonly in wheat;
casein is a milk protein. Many autistic children find that their bodies are unable to
digest these proteins and therefore they can become harmful to them. Studies have
shown that most children who have autism also have “inflamed gastrointestinal
tracts” (McCandless, 2007, page 27). This can damage the child’s immune system
as “70% of immune cells are in the digestive tract” (Davies, 2012, page 137). When
foods containing gluten and casein are introduced to the intestinal tract, they can
irritate and inflame the intestine causing symptoms such as stomach pains.
According to McCandless 2007, autistic children with inflamed intestines are
particularly susceptible to yeast infections and more specifically a species of yeast
known as Candida. This will be explored further on in the review.
Angley et al, 2007, published an article which highlights the issue of inconsistent
results from research into the efficacy of GF/CF diets. She compared two studies
which look at the results of GF/CF diets and their outcomes on children with autism.
The first study was a randomised single blind study on 20 autistic children,
conducted by Knivsberg et al, 2002. This study assessed the effect of “a gluten-
casein free diet on children with autistic syndrome and urinary peptide abnormalities”
(Elder et al, 2006, page 415). The children were separated into either the control

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group or the experimental group. Findings showed that the experimental group who
received the GF/CF diet exhibited improvements in “behaviour, non-verbal cognitive
level and motor problems” (Elder et al, 2006, page 415). The second study was
Elder et al’s 2006 efficacy study of GF/CF dietary interventions for children with
autism. This study was a double-blind randomised study of 15 children conducted
over 12 weeks. Results found “no statistically significant findings even though
several parents reported improvement in their children” (Elder et al, 2006, page 413).
This provides conflicting results to the success of Knivsberg et al’s 2002 study thus
throwing the efficacy of GF/CF dietary interventions for autistic children into the air.
From these results it is not possible to draw a substantial conclusion of the success
of these diets. The difference in the ‘single-blind study’ and ‘double-blind study’ could
provide a reason behind the differing results as the single-blind study conducted by
Knivsberg et al 2002 risks the contamination of bias within its research. Elder et al
2006 have avoided the possibility of bias by using a style of research that renders all
participants and researchers ignorant of which subjects are receiving what.
Therefore it could be argued that Elder et al’s study has more reliability and thus
more efficient results. However the sample sizes of both studies are too small to
represent a sufficient average of the population of autistic children. As stated by
Elder et al 2006, “a need still exists for rigorous controlled clinical trials evaluating
both physiological and behavioural effects” (page 415).
In 1991, Dr Kalle Reichelt studied the urine of children with autism and found that
these children had high levels of peptides in their urine which were not found in the
urine of typically developing children. Peptides are compounds which enable the

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breakdown of protein and those found in the urine of the children studied derived
from gluten and casein in the diet. Amongst those peptides found in the urine were
casomorphins, which come from casein. These high levels of casomorphins can be
explained by a lack of the specific enzyme needed to break this peptide down.
Research into this specific enzyme was pioneered by Dr Alan Friedman 2000 and
his colleagues. They looked into the possible role of a lack of the dipeptidyl
peptidase- IV (DPP-IV) enzyme in children with autism. This is “the only known
enzyme to break down casomorphins” (Smeltzer, 2011, page 16) and therefore vital
to ensure the upkeep of protein levels within the body. DPP-IV is also imperative in
the digestion of gluten and casein. According to Friedman et al 2000 this enzyme
can be found in areas such as the small intestine and the blood-brain barrier which
shows how widespread it can be. Through his research, Friedman et al 2000 found
that nearly 100% of the autistic children involved in his studies had “casomorphin
and gliadomorphin peptides in their urine unless they were on the GF/CF diet”
(Smeltzer, 2011, page 16). McCandless 2007 describes how a lack of an active
DPP-IV enzyme in the body can cause a build-up of ‘demorphins’. These are “opioid
or morphine-like substances” (McCandless, 2007, page 27) which when
accumulated in the body can be a contributing factor to autistic children often
appearing “spaced out” (McCandless 2007 page 27).
1.4) Opioid-Excess Theory
“It has been suggested that peptides from gluten and casein may have a role
in the origins of autism and that the physiology and psychology of autism

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might be explained by excessive opioid activity linked to these peptides”
(Millward et al, 2008, page 2).
The above quote introduces the theoretical basis for a diet free from gluten and
casein; the ‘opioid excess theory’. McCandless’s 2007 idea that children can appear
‘spaced-out’ can be explained by this theory. It is suggested that the peptides
excreted by the gluten and casein in the child’s diet are incompletely metabolised
and remain active within the body, exhibiting opioid activity. Isherwood et al, 2011
propose that these ‘toxic’ peptides pass through into the central nervous system and
“interfere with the neurotransmission causing altered or disrupted activity and
altered-sensory input” (Isherwood et al, 2011, page 59). The opioid activity of the
peptides can be likened to the effects of opiate drugs and can cause “significant
problems with speech, communication, behaviour and social skills” (Tommey and
Tommey, 2011, page 58). It compares the symptoms of autism with the behaviours
exhibited when one is using opiates, such as heroin. Thus, the opioid-excess theory
attempts to provide an explanation for the different behaviours and symptomatic
tendencies observed in autistic children.
Whilst this theory is being discussed in current society, the link between opiates and
autism was highlighted by Jaak Panksepp 1979. Panksepp used research into the
effect that low doses of narcotics such as morphine can have on emotionally
compromised animals to explore the link between the opioid state of autism and the
long-term effect of narcotics. He reported similarities between the opioid symptoms
noted in children with autism and the effects of long-term morphine use (Shattock;

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Whiteley, 2002, page 2). According to Panksepp 1979, the similarities found, which
included a deficient desire for social companionship,
“suggests that the underlying neurochemical imbalance in autistic children
may be excessive, or unusual, activity in their own endogenous brain opiate
systems”. (Panksepp, 1979, page 175)
Whitely and Shattock, 2002, blame the success of these peptides entering into the
central nervous system on an “abnormally permeable intestinal membrane”
(Shattock; Whiteley, 2002, page 1) which allows the peptides to have a detrimental
effect on the brain’s neurotransmitters. It permits the disruption of “a variety of
biochemical and neuroregulatory processes” (Shattock; Whiteley, 2002, page 2).
In context of the opioid-excess theory, Shattock and Whiteley promote the exclusion
of food substances which subject a child to these harmful casomorphins and
gliadomorphins. Thus, Shattock and Whiteley 2002 support the dietary intervention
of removing gluten and casein from the diet of an autistic child. However,
Schreibman wrote in 2007 that this theory “remains speculative at this point”; a
contrasting and sceptical perspective on the opioid-excess theory. Schreibman
draws attention to the fact that this is a ‘theory’ and therefore it will inevitably
encounter scepticism and opposing opinions.
1.5) Biomedical Approach

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There is much research and literature that delves deep into the field of biomedical
approaches to treatment for children with autism. The biomedical causes of autism
are widely discussed amongst Defeat Autism Now! (DAN!) Doctors, who believe that
biomedical treatment can be used to positively affect the behavioural and cognitive
symptoms of autism. Jaquelyn McCandless MD, 2007, is a strong supporter of the
biomedical approach to autism, believing that “sometimes the improvement is
dramatic enough for a child to lose his or her ASD diagnosis” (McCandless, 2007,
page 6). This bold statement highlights the end goal that biomedical treatment seeks
to reach, however it must be noted that this is a sweeping statement and will only be
true for a handful of children. However, the idea has now been introduced, thus
further exploration of the possibilities of ASD recovery or symptom improvement is
anticipated.
1.6) Defeat Autism Now!
Defeat Autism Now! (DAN) was formed to “focus activism and attention on identifying
the biological bases of autism and biologically based treatments” (Schreibman, 2007,
page 23). This organisation was set up in 1995 by a combination of parents,
researchers and physicians all with a vested interested or connection to autism. It
provided a new way of thinking about the causes and treatments of children with
ASD from a biological perspective and offered new information about the effects that
factors other than behaviour can have on these children. It focuses on dietary and
biomedical approaches to autism including restrictive diets and nutrient supplements.

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Tommey and Tommey 2011 present a clear theme throughout their book (Autism: A
practical guide to improving your child’s quality of life) of optimism that a child’s
autistic behaviours and symptoms can be greatly improved. The title itself suggests
that this book will ensure a child with autism will have a better life once they apply
themselves to this guiding piece of literature. However, it must be taken into account
the possibility of bias presented by Tommey and Tommey 2011. A couple, their
eldest son was diagnosed with autism when he was only 2. Together they delved
deep into the world of autism; its causes, treatments and the connections between
biology and medicine, all of which resulted in successful ‘treatment’ of their now high
functioning teenage son. Their individual success story however must not be
accepted as the finding of a general solution to the problems associated with autism.
Whilst this book does provide extensive information on diet and nutrition and the
positive effect this can have on a child with autism, it does not guarantee that all
children will have such positive results. Their own enthusiasm for dietary and
biomedical intervention stems from the success their son has gained from it.
Tommey and Tommey 2011 do acknowledge the uniqueness of every child “we have
learned one very valuable lesson: that each and every child with autism is different”
(Tommey and Tommey, 2011, Page xiv).e topic.
1.7) Nutritional Standards
It is important to acknowledge the legislation that sets out standards for dietary
provisions for children in education. In terms of children’s diet during the school day,
schools have strict nutritional standards to adhere to in what they offer children. In
2005, the School Meals Review Panel (SMRP), chaired by Suzi Leather, released a

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report on “the development and implementation of nutritional standards for school
lunches” (DfES, 2005). The report sets out the panel’s recommendations for change
and development of the food served in schools, based on evidence from a variety of
sources including head teachers, school caterers and public health experts. It
provides a framework for school catering staff to follow in order to ensure that they
serve “well-cooked, well-presented meals, made from good-quality ingredients to
accepted nutritional standards”; whilst also ensuring that they are confident in their
own abilities as catering staff.
The SMRP’s 2005 report does not detail the specific nutritional standards that should
be met by special schools or those catering to a special educational needs unit. The
only incidence where Leather explores the relationship between special schools and
the food provided is in the interest of eligibility for free fruit and vegetables in the
School Fruit and Vegetable Scheme. This however is neither a recommendation put
forth by the review panel nor a target; it was put into practice in 2000 by the NHS
and is merely highlighted as a ‘recent development’. It is also not limited solely to
special schools, but rather eligibility for a free piece of fruit or vegetable spans nearly
2 million children in over 16000 infant, primary and special schools in England
(Department of Health, 2010). Therefore it is apparent that Leather 2005 does not
adequately address the difference in dietary needs between typically developing
children and children with autism.
In its recommendations, the panel set forth a table of Nutrient Standards which lists
the proportions of each nutrient that should be present in the school lunches offered
to children and young people. The table states that across the five consecutive

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school days, lunches should contain a quantity of carbohydrate that amounts to no
less than 50% of food energy. Carbohydrates provide the body with energy which
according to studies can have positive effects on children. In a study by Vaisman et
al 1996 it was suggested that cognitive performance can be increased in those
children who do not typically eat breakfast just by providing them with breakfast,
which generally includes carbohydrates. This supports Leather’s recommendation
that the Government should prioritise the supplement of breakfast standards in
schools.
This highlights a major lack in the legislation surrounding the nutritional standards
that must be upheld for children with disabilities. Yet the creation of such standards
risks straying into discrimination against children with disabilities and labelling them
as ‘an exception to the dietary norms’ associated with typically developing children.
The fear of being accused of discrimination suggests that this is an area that few are
willing to explore. Instead, all children, regardless of whether they are typically or
atypically developing, are provided for in schools following the same nutritional
standards framework. Literature that proves that this may indeed be harmful to
certain children appears to simply be ignored. Although there is a wide variety of
information on diet and autism available on the internet, this too has been
overlooked in terms of the national dietary nutritional standards set out by the SMRP
2005.
1.8) Carbohydrates and Candida

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However, for children with autism, refined carbohydrates such as white bread and
crisps generally prove problematic for their gastrointestinal systems and if consumed
at the rate suggested by Leather 2005 would have negative consequences. Tommey
and Tommey 2011 explain that these refined carbohydrates “provide exactly the right
nutrients (mostly glucose) for Candida to thrive on and can upset the blood sugar
balance” (page 65). An increase in Candida has been suggested by some research
to be “a significant cause of many of the untoward behaviours and health problems
we see in autistic patients” (McCandless, 2007). Shaw, 2002, looked more closely at
the link between yeast and the effects it has on children with autism. He explained
that as Candida multiplies, it excretes toxins into the body. He suggested that these
toxins “are capable of impairing the central nervous and immune systems” (no
pagination). This audacious statement suggests that children with autism who have
an excessive amount of Candida in their bodies could become seriously physically
challenged and unwell. McCandless’s inclusion of this research suggests that she
supports Shaw’s findings. While she includes them as “ground-breaking research”
(McCandless, 2007, page 28), there is a lack of further exploration of the link
between the yeast toxins and the nervous and immune system. This is a bold area of
research which suggests highly negative results on children with autism; therefore
the author may have missed the opportunity to provide further understanding of this
link.
McCandless 2007 also explores other symptoms that can occur from excessive
Candida growth in children with autism. She lists “diarrhoea, stomach ache, gas
pains, constipation, headache, fatigue and depression” (McCandless, 2007,
page28). This cocktail of symptoms would be difficult for a typically developed adult

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to deal with, let alone a child with autism whose development has already been
compromised. McCandless also lists behavioural problems that can occur due to
Candida overgrowth, which include “concentration difficulties, hyperactivity, short
attention span, irritability and aggression” (McCandless, 2007, page 28). From these
lists we can deduce that Candida is not only harmful in terms of physical health, but
it can also be damaging to behavioural development. Therefore its importance must
not be overlooked. However, McCandless clearly does not rate the issue of Candida
as highly as there is little further exploration of the subject within her book. The next
section of this body of work is a study of the popularity of dietary interventions
amongst children with autism and a discussion into the efficacy of such interventions.

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Chapter_2
Methodology
The purpose of this study was to look at the different foods that children with autism
are consuming on a day-to-day basis in their educational setting. The researcher
wanted to gather data that could be analysed and compared to the restrictions of a
gluten-free and casein-free diet, as well as other dietary interventions.
Questionnaires were sent out to parents to determine the level of knowledge on
dietary interventions and to gather information on parental stance concerning a child
with autism’s dietary intake. Finally, a case study was drawn up by the researcher
using a subject who is currently undergoing a dietary intervention to provide a time-
line of intervention and results.
2.1) Participants
School Meal-Time Setting
The research question focuses on the affects that diet can have on ‘children’ with
autism. The first participants involved were a group of Key Stage 3 and Key Stage 4
children with autism aged between 11-16 years. The research was conducted in a
special school with a separate specialised department for children with autism. As
this part of the research was a general observation of a meal-time setting, personal
information including age of each individual was not noted but rather an average age
range was provided. These participants were all on the Autistic Spectrum. Two

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different lunch time proceedings were observed on the same day therefore providing
a range of results.
Food Diaries
7 children from this group of participants also participated in another stem of
research. These 7 children were observed by their teaching assistants (TAs) over a
period of 5 consecutive school days. The TAs recorded the data for this aspect of the
research although the children were the subjects of this research. The TAs remained
anonymous and their data collection was passed to the researcher by the Head
Teacher’s PA. The overall number of TAs involved in this research also remained
anonymous as the research was conducted at the school in the absence of the
researcher.
Case Study
The participant in the case study, ‘Child-X’, is a 5 year old autistic child known to the
researcher. The researcher elected to write up a case study of Child-X as he
provided a current and first-hand experience of the effects of dietary intervention.
The parents of Child-X were also included in the collation of information for this case
study.
2.2) Research Methods

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Before research was conducted, the researcher met with the Head Teacher of the
chosen school to discuss the proposed research and arrange a time and date to
conduct it. This meeting lasted an hour and allowed the researcher to provide the
Head Teacher with food diary templates to be passed to the TAs for completion. It
was decided during this meeting that the observational research would be
undertaken on one day, therefore allowing for minimal disruption to the children in
the school. As the researcher was looking for qualitative data from educational
research, the choice of observational research correlated with Levin, O’Donnell and
Kratochwill’s 2003 ‘Stages of Programs of Research’. Levin et al 2003 suggested
that the first stage of educational research would involve “observational, focused
exploration” and the second stage would consist of “observational studies of
classrooms” (Brantlinger et al, 2005, page 145). The school has 2 lunch-time sittings
(12:15-12:45 and 12:45-13:15) and the observations were to span both sittings. An
informal meeting with the head chef of the school was scheduled to be held between
the two sittings and after lunch.
The researcher completed the observational research in the dining hall of a school
for children with learning difficulties. The researcher initially observed the food that
was being served as it was delivered to the dining hall. The researcher questioned
the head chef on the menu and noted the food on offer that day. This part of the
observation was conducted in the absence of any children and only involved the
catering staff of the school.
The second part of the observation was completed once the first group of school
children had entered the dining hall for their lunch-time sitting. The researcher

27 |
moved around the dining hall, taking a tally of the different food and drink each child
was consuming. The researcher conversed with TAs present in the dining hall to
establish the various dietary restrictions and requirements of some of the children.
As this was only observational research in terms of the children’s participation, there
was no conversation between the researcher and the children. The researcher
observed the main course and desert choices made by the children at the food
station as well as the drinks chosen. Those children who brought a packed lunch
with them were also included in the research checklist tally. This observation
research was repeated for the second group of school children in the second lunch-
time sitting.
2.3) Research Instruments
Observational Research
Pre-observation, the researcher created a ‘research checklist’ to be taken to the
observation and used to note a tally of results. The checklist, shown in Appendix.1
allowed the researcher to make note of the different food groups eaten during the
lunch setting; the individual foods that comprised these food groups; the different
drinks consumed and the quantity of children consuming these foods and drinks.
Whilst there was a column titled ‘solid food’ this was discarded on observation as it
became apparent that it was a redundant variable. The final column on the research
checklist, titled ‘restricted diet’, was completed through observation combined with
conversation with the catering staff. This type of research allowed the collection of
both qualitative and quantitative data. The quantitative data collected through the

28 |
tally lent itself to the presentation of findings in graphs and charts. “Graphs and
charts condense large amounts of information into easy-to-understand formats that
clearly and effectively communicate important points” (CDC, 2008, page 1). The
categorical data of food types etc. is best represented in these forms.
Questionnaire
The questionnaire was structured into two sections which were signposted within the
questionnaire. Sectioning ensures that questions “are not constantly shifting back
and forth” (Anderson, Arsenault, 2005, page 187) therefore allowing a fluency to the
questionnaire. The first section aimed to find out about the child in general, therefore
enquiring about age, sex, disability, medication and verbal ability. The second
section of the questionnaire was more related to the research aims and asked
parents about the food habits of their children and their knowledge surrounding
dietary interventions. The questionnaire combined a mixture of closed-questions
such as tick-box style questions; and open-ended questions which provided
descriptive answers. They enabled the researcher to compare the parental
perspectives in the questionnaire to other parts of the research, such as the case
study.
Case Study
The researcher created the case study through an informal meeting with Child-X and
his mother and father. Although the researcher had a vague structure for an
interview regarding the timeline of Child-X’s dietary intervention, the meeting was led

29 |
by the parents, with the researcher noting down everything that was said. The
structure consisted of ‘Summary’; ‘Issue to be resolved’; ‘Action taken’; ‘Results’;
‘Next steps’ and ‘Any other information’. This structure was used to gather
information for each section of the timeline. The researcher explained the structure
of the interview to Child-X’s parents and asked that they provide a detailed timeline
of events that set out all intervention Child-X has received along with effects on the
child; behavioural changes; physical changes and the results of all treatment.
2.4) Ethical Issues
Before any research was commenced, the researcher created a parent information
sheet detailing the proposed research and the dissertation question. This was drawn
up to ensure that parents were as fully informed as possible about the intended
research on their children. A separate information letter was also created which
provided information on the questionnaire. Both letters are shown in Appendix.2 and
Appendix.3. The researcher wrote two separate information letters for the different
stems of the research to ensure the elimination of any confusion surrounding the
research. The researcher wanted to make a clear definition between the two stems.
Two separate consent forms were also created for the questionnaire and the
observational research to continue to ensure a consistent definition between the two
branches of research (these are shown in Appendix.4 and Appendix.5).
The questionnaires sent out to parents (see Appendix.7) provided the researcher
with a particular ethical issue. The Head Teacher of the school explained that
roughly 80% of the parents of the pupils did not have English as a first language.

30 |
The issue then arose of whether they would fully comprehend the information
provided in the information letter and the consent forms. The researcher questioned
whether informed consent would be possible to ascertain if the parents could not
understand English. The decision was made by the Head Teacher that all the letters
would still be sent out as the research involving the children was purely
observational but that the consent forms should be altered to ‘opt out’ forms rather
than ‘opt in’. The change to the forms was made by the Head Teacher as she agreed
she had a greater understanding of the literary and comprehensive backgrounds of
these parents.
An issue arose in the return of the questionnaires. As only 3 were returned from the
entire school, the researcher was faced with a sample-size that was too small to give
a reliable overall view of the parental perspectives. Therefore the researcher had to
decide whether this was valuable research that should be included. It was decided
that the questionnaires provided the researcher with a wider understanding of
parental perspectives on dietary interventions for children with autism, yet the
information did not need to be included in the overall research study. It was to be
used to inform the researcher but not the research.
The researcher had to be particularly sensitive to minimising disruption to the routine
of the autistic children. A trait of many children with autism is their obsessive and
compulsive behaviour and their need for a repetitive routine. Therefore, being a
stranger, the researcher had to be careful not to upset the children by interfering too
much in their daily routine. The researcher observed as much as possible from

31 |
outside of the dining hall and when walking around the hall, the researcher was
careful not to invade any child’s personal space.
The dissemination of the information gathered and management of such information
provided an ethical issue of anonymity and confidentiality. Every participant has the
right to remain nameless and also for their input to remain private. Wiles et al, 2006,
describe Oliver 2003 and Gregory 2003’s principle of privacy as a principle that is at
the heart of our society. We believe “that individuals matter and that individuals have
the right for their affairs to be private” (Wiles et al, 2006, page 2), therefore the
researcher upheld complete confidentiality with all participants. Within the case
study, the child was referred to as ‘Child-X’ throughout and the parents were fully
informed of the inclusion of the case study within this research. They agreed to the
display of the case study as a chronological timeline of data on the understanding
that the researcher does “not disclose identifiable information about participants” and
tries “to protect the identity of research participants through various processes
designed to anonymise them” (Wiles et al, 2006, page 2). They were given the
options to create pseudonyms however they opted simply for ‘mum’ and ‘dad’.
The researcher was also aware of the sensitivity surrounding the food diaries sent
out to parents. As these diaries were designed to extract information on what parents
fed their children, there was an issue in ensuring that parents were not being ‘judged’
about what they gave their children. The researcher made it clear that this was an
optional diary and that any information would remain anonymous. However the
researcher was aware of the participants and therefore would know which diary

32 |
came from which family. This could explain the lack of returned food diaries that the
researcher received.

33 |
Chapter_3.0
Presentation and Analysis of Findings
3.1) Observational Research Results
The first part of the research that was collected was the primary data from the school
meal-time setting observation. Appendix.1 shows the research instrument used to
collect the data. Results were converted into graphs and charts to enable clear
portrayal of the results. It is important to note that the results of the meal-time
observation include foods from both the school catering and a few packed lunches
so as to get a rounded view of the
food children eat at lunch. The
following section displays the
results of the research and
provides an explanatory aside to
each.
Figure.1) is a pie chart that
displays the percentages of the different types of consumed nutrients that were
noted during observations of
autistic children during their lunch
break. It shows a majority of
carbohydrates and a minority of
protein. The chart was created from results of the research checklist (Appendix.1).
Carbohydrate Protein Fruit/ Vegetable Dairy
Different types
of nutrient
12 1 5 2
60%
5%
25%
10%
Chart Percentage of different
Nutrients consumed during
school meal-time observation
Carbohydrate
Protein
Fruit/ Vegetable
Dairy
Figure 1) A pie chart showing the quantity of each nutrient consumed
during the meal-time observation
Table 1) The different number of eachindividual nutrient observed.

34 |
Table 1) shows the raw data from the observational research, before it was
converted into the chart in Figure.1). For example, Table 1 shows that only one type
of protein was consumed compared to a variety of different carbohydrates.
Figure.2) is a graph
showing the amount
of times each
different nutrient
was eaten. For
example, the table
shows that fruit and
vegetables were
eaten 30 different
times throughout
lunch-time. The table provides quantitative data regarding the popularity of each
nutrient. It shows the number of times the different nutrients were actually
consumed, rather than just the number of times they were on offer. The researcher
collected this data to gain an understanding of the foods autistic children eat through
choice and naturally lean towards. It therefore provides a base from which further
food preferences can be guessed.
From Figures.1) and 2) we can see that not only were the carbohydrate rich foods
most readily available, they were also the most popular in terms of consumption.
There were 46 different instances of children eating carbohydrates, compared to only
46
20
30
4
0
5
10
15
20
25
30
35
40
45
50
Instances of
Carbohydrates
consumed
Instances of
Protein
consumed
Instances of
Fruit/Vegetable
consumed
Instances of
Dairy
consumed
Number of instances each nutrient
was consumed
Figure 2) A graph displaying the amount of times each nutrient was eaten.

35 |
4 instances of dairy consumption. Although there was only 1 type of protein available
to the children observed, it was clearly a popular choice as there were 20 instances
of it being eaten. This indicates that the variety of each nutrient on offer does not
have a direct effect on its overall popularity as the limited option of 1 type of protein
proved more popular than the 2 types of dairy available.
3.2) Carbohydrates
The percentage of carbohydrates consumed by the children observed has been
broken down in Figure.3) into the different food products.
Figure.4) presents the
percentage of the different fruit
and vegetable products
consumed during the meal-time
observation. The pie chart
shows a total of 5 different
35%
7%
20%
2%
2%
2%
2%
18%
2% 4%
4%
2%
Percentage of each different type of
carbohydrate consumed
Spaghetti
Jacket Potato
Garlic Bread
Mashed Potato
Jam Sandwich
Crisps
Tortilla Chips
Rice Pudding
Fairy Cake
Butter Sandwich
Biscuits
Chapati
Figure 3) Chart showing a breakdownof the carbohydrates consumed
36%
37%
17%
7% 3%
Percentage of each different type of
Fruit/ Vegetable consumed
Sweetcorn
Carrot
Salad
Apple
Banana
Figure 4) A pie chart showing the percentage of each fruit/vegetable
consumed during the meal-time observation.

36 |
fruits/ vegetables. Potato has been eliminated.
Figure.5) shows the
children’s drink
choices. The only drink
option offered by the
school was water. The
Capri Sun and the
juice were provided in
3 packed lunches and
were not offered by the
school. These results
have been included to draw attention to the possible relationship between the drinks
consumed by the children and the ensuing effects upon them. Whilst the majority of
the children drank water; the Capri Sun and the juice are sugary drinks and therefore
should be considered in terms of effect of sugar on children with autism.
3.3) Food Diaries
Appendix.6 and Appendix.7 show eight food diaries that were completed for the
researcher either by a TA (Appendix.6) or a parent (Appendix.7) of an autistic. Seven
of these food diaries provide an overview of the foods children with autism consume
whilst in school; showing show break-time and lunch-time food and drink intake from
Monday- Friday. Appendix.7 is a food diary which shows Child H’s food and drink
intake across a full week, listing breakfast, lunch and dinner in both an educational
11
1 2
0
2
4
6
8
10
12
Water Capri Sun Juice
NumberofPupils
Type of Drink
Graph showing the number of pupils
consumingdifferent drinks
Type of Drink
Figure 5) A graph showing the number of pupils consuming each type of drink.

37 |
and a home setting. The layout is different as it spans 7 days (Monday-Sunday). It
has a different colour scheme and layout so as to highlight its separation from the
other diaries and to eliminate confusion with them. Appendix.7 was completed to
provide an insight into the difference between food intake at home and in school.
All food diaries were completed independent of the researcher and returned either to
the child’s school where they were passed on to the researcher, or direct to the
researcher via email. The children whose food diaries were completed by their TAs
are pupils at the same school where the meal-time observation was held and were
also involved in the
observation.
Figure.6) displays the
quantity of each nutrient
present within the 7
school-based food diaries.
The pie chart shows a
fairly even spread across
the five nutrients; the most common nutrient is carbohydrate. It shows that only a
small percentage of the foods were protein, which correlates with the small amount
of protein on offer in the school meal-time setting, as depicted in Figure.1).
3.4) School Lunch 4 Week Menu
Figure 6) A pie chart showing the percentage of each nutrient listed in the 7
school-based food diaries.
36%
14%
26%
19%
5%
Overall Percentage of each food
type from the school-based food
diaries
Carbohydrates
Sugar
Fruit/Vegetable
Dairy
Protein

38 |
Appendix.9 is a scanned image of a document that outlines a 4 week menu
framework for the school dinners on offer at the participating school It has been
included to offer an insight into the food and diet provided by mass catering
companies and the education system. It shows an average 4 week menu with a
meat main, a vegetarian option, vegetable sides and a pudding.
3.5) Case Study
A case study was conducted on a 5 year old boy with autism, known as ‘Child-X’,
who now follows a strict dietary intervention as suggested by a Clinical Nutritionist
(CN) following the Defeat Autism Now! (DAN!) protocol. The case study outlines a
chronological timeline starting from the age of 2. Before the age of 2, Child-X’s
development appeared typical and gave mum and dad no cause for concern. The
case study details the treatment and intervention Child-X has received throughout
his life so far. It also explains the developmental obstacles, challenges and
milestones.
 First 13 months-
Child-X was very sick. He contracted a chest infection and was given
antibiotics.
MMR Jab
Child-X received the MMR vaccination. However, due to his compromised
immune system he couldn’t cope with the MMR jab.
 2 years old-
No speech or vocabulary

39 |
Example: No verbal communication.
Mum contacted Child-X’s nursery for feedback on Child-X’s development,
behaviour and social interaction. Nursery provided minimal information and
expressed no worries about Child-X’s social and emotional development.
 2 years 6 months-
General Practitioner visit
Mum contacted her GP with concern over Child-X’s lack of speech and
language. GP told mum not to worry; boys are often slower developing. GP
dissuaded a referral to a speech and language therapist and told mum to
return after 3 months as GP felt Child-X’s speech and language would
develop.
Initial referral to speech and language therapist
After no improvement GP referred Child-X to a speech and language
therapist.
Visit to South Africa and Tympanometry test
Family visited a doctor friend on holiday in South Africa. Doctor referred Child-
X to a specialist who tested the child’s speech and hearing, using a
tympanometry test. Test concluded normal hearing however the child did not
respond positively to the hearing test.
Observed in play situation
Doctor observed child playing outside. Child-X immediately played on
climbing frame with his father. He also sat on the doctor’s lap. These

40 |
observed social skills and behaviours prompted the doctor’s opinion that
Child-X was not autistic.
 3 years
Started speech and language sessions. SALT referred Child-X for a hearing
test and Cognitive Development Assessment.
Cognitive Development Assessment
Child-X received a Cognitive Development Assessment. Results showed he
was on par with his age group for everything except his manipulative skills
and his speech.
Example: Child unable to draw a circle.
Paediatrician contacted nursery
Even though parents had regularly contacted Child-X’s nursery to discuss any
abnormal behaviour or issues, to which the nursery expressed no concern
and said Child-X played and socialised with his peers, when Child-X’s
paediatrician contacted the nursery, they expressed concern about Child-X’s
social behaviour. Paediatrician suggested that Child-X may have autism but
must wait 6 months for a further assessment.
 During the 6 months between 3 years 3 months and 3 years 9 months-
Physical changes noted with Child-X
Child-X appeared grey; his hair had lost its shine and his behaviour
deteriorated. He had frequent and worsening tantrums. He wouldn’t settle and
woke up throughout the night.
Constipation

41 |
Child-X suffered chronic constipation. He was eating normally and taking the
laxative supplement Lactulose (prescribed by his GP).
Appointments for assessment
Child-X received an appointment for a follow up cognitive assessment and for
a multi-disciplinary assessment.
 03/10/2012 4 years old-
Multi-disciplinary assessment and diagnosis
Child-X was assessed in his home setting, his nursery setting and the
paediatrician’s offices. This resulted in a diagnosis of autism. Mum and Dad
only received an information leaflet on autism.
Contacted DAN campaign follower
Mum and Dad rang a contact in America who follows the Defeat Autism Now!
(DAN) protocol who explained the dietary changes that the DAN protocol sets
out and provided her son’s success story from these dietary changes.
 06/10/2012 4 years 3 days-
Child-X began immediate gluten and dairy free diet.
Child-X had processed food and anything with additives especially E-numbers
and unnatural colours removed from his diet.
 07/10/2012 4 years 4 days-
Child-X’s first noted response to instruction and verbal interaction.
Example: Dad gave Child-X a flower and told him to give it to his mummy.
Child-X took the flower to his mother and said “mummy”.
 Commencement of supplements.
Child-X began taking refined cod liver oil, calcium magnesium, multi-vitamins
and a clay mixture. He began bathing in Epsom salts. Prior to Epsom salts

42 |
Child-X would only bath alone. First time Child-X soaked in Epsom salts he
allowed Dad to share the bath, laying on him calmly. Child-X began taking a
probiotic a few weeks later.
 10/01/2013 4 years 4 months-
Meeting with Clinical Nutritionist
Child-X’s had a Skype meeting with their CN. Child provided the lab
(recommended by the CN) with a urine, blood, hair and stool sample. CN
requested that Child-X cease all dieting and provide 3 different stool samples
for the months of January and February. CN tested Child-X for gluten and
dairy intolerance; worms and dilated pupils- Child-X tested negative for all.
Beetroot and Urine Test
Child-X drank 250ml of a solution of beetroot. Urine was then examined for a
desired pink hue which would suggest typical bodily functioning. Urine
showed no pink. Child-X also had his urine tested for crystals but none were
found.
Hair Sample
Results showed that Child-X had more toxins in his body than in his hair,
whereas typically the majority of the toxins should be found in the hair.
Biomedical Test Results
Majority of calcium found in hair as opposed to where it should be i.e. body.
Blood Test
Child-X tested for gene mutation and found to have glutathione mutation, a
deficient gene.
 March 2013

43 |
Mum and Dad contacted their CN to discuss results of tests and arranged 3
monthly consultations over Skype. They were told to give Child-X a mixture of
different nutrient supplements. Altogether Child-X took 21 nutrient
supplements, listed below.
21 Nutrient Supplements:
 Coenzyme Q10 (COQ10)
 Vitamin A
 Vitamin C
 Vitamin D
 Vitamin E
 Vitamin B12
 Seratonin
 Zinc
 Alpha lipoic acid (detoxifier)
 ADP (oregano)
 Culturelle Probiotic
 Mindlinx Probiotic
 Permatrol
 Phosphatidylserine
 Candiclear
 Aloe Vera juice
 Calcium Magnesium
 Refined Cod Liver oil
 Folinic Acid with B12
 Primal Defence

44 |
 Secretin
3.6) Results of Nutrient Supplementation and Dietary Intervention
 Prior to treatment Child-X could only produce a
stool once a week. This progressed to 4 times a
week during intervention. Results are now 13
times in 14 days.
 Child-X had never engaged in play with scooters
before treatment. After watching Dad play on a
scooter for a number of days, child picked up a
scooter and began scooting.
 Child-X’s speech and word recognition is much
improved compared to his total lack before
treatment. Child-X can cite words and read comprehensively.
 Figure.7) shows Child-X’s painting ability. The picture is a self-portrait Child-X
completed at school.
 Child-X goes to mainstream school but receives full support 32 hours a week.
 Child-X has made friends. During play time he interacts with other children.
Child-X used to be unaware of others; now he asks for absent people.
 Child-X understands to line up after break-time at school and shows
understanding of the school bell system.
 Child-X baths himself and washes his own hair. He is also able to dress and
undress himself without help.
Figure 7) A self-portrait painted at school
by Child-X.

45 |
3.7) Average financial costs of treatment
 On average £300- £550 a month
 £1400 for the tests completed in February 2013
 £500 on products
 £300 on supplements
 Everything given to Child-X is organic, gluten free and dairy free.

46 |
Chapter_4.0
Discussion of Findings
The results from this piece of research provide many platforms for further exploration
into the relationship between dietary interventions and children with autism. The
findings from the observational research in a school meal-time setting and the food-
diary results offer a base for further study into the effects of individual nutrients on
children with autism. The case study allowed the researcher to delve deeper into the
field of dietary intervention with a link to a gluten-free diet. The following section
discusses the results of the research findings and explores these aforementioned
areas.
4.1) Carbohydrates
The pie chart in Figure.3) shows that the main carbohydrates consumed by the
children were potato, pasta and bread products. Statistics show that 35% of the
carbohydrate food products were spaghetti, which proved the most popular option for
the children with autism. The results of the 7 food diaries completed by the children’s
TA’s showed that the quantity of carbohydrates consumed outweighed the quantities
of other nutrients. In total, 36% of the overall nutrients recorded in the food diaries
were carbohydrate. Whilst this is 24% less carbohydrate than that which was
recorded in the school-meal time setting, it is still the majority percentage compared
to the quantities of protein, dairy, fruit/vegetable and sugar. This highlights the

47 |
popularity of carbohydrates and suggests that children with autism have a high
carbohydrate intake.
Potato products such as crisps and bread products made from enriched or bleached
flours such as white bread come under the category of ‘refined carbohydrates’.
These carbohydrates are detrimental to a child with autism in relation to the candida
harvesting they permit. Therefore it is alarming to note that 91% of the carbohydrates
recorded in the school meal-time setting were refined carbohydrates. The only
options for non-refined carbohydrates were the potato products ‘mashed potato’ and
‘jacket potato’. These options are also gluten-free options. The researcher made a
note that most of the autistic children who opted for a potato product carbohydrate
did so due to wheat intolerances preventing them from choosing the pasta and bread
options. This suggests the hypothesis that unless restricted by a particular allergy or
intolerance, the majority of children with autism will choose a refined carbohydrate
product that contains gluten.
What is immediately obvious from the findings of the observational research and the
food diaries is the vast percentage of carbohydrates being consumed. An increase in
candida in the child’s body upsets the blood sugar balance. Srinivasan 2009
explained that the toxins that are produced by the Candida yeast “could cause some
of the symptoms [of autism] directly or by overloading the detoxification pathways”
(Srinivasan 2009 page 242). Candida has also been linked to damage of “the
nervous and immune systems” as well as “a variety of behaviour and health
problems” (Brill, 2001, page 21). Yet carbohydrates were the most commonly
available nutrient for these children to eat. Figure.2) depicts the popularity of each of

48 |
the different nutrients and shows that carbohydrates were consumed the most. This
carbohydrate-rich diet guarantees many children with autism a gut filled with
Candida yeast and therefore a plethora of different gastro-intestinal issues as noted
in the Literature Review section.
Edelson 2003 noted some of the behavioural and health effects of Candida
overgrowth on children with autism included irritability, aggression, stomach aches
and constipation. Yet Figure.2) shows that the negative effects of carbohydrate
consumption on a child with autism haven’t affected the availability of carbohydrates.
Srinivasan describes a diet that provides an alternative menu. The “Body Ecology
Diet” was initiated by Donna Gates and focuses on “rebuilding immunity and
intestinal flora” (Srinivasan 2009 page 244). It limits carbohydrate consumption and
also focusing on the upkeep of beneficial flora in the gut. The diet challenges the
issue of Candida overgrowth through its very limited allowance of carbohydrates. It
insists on a drastic reduction in consumption of sugar and carbohydrates. In
particular concentrated carbohydrates such as potato and refined sugars must be
removed.
Williams et al 2011 researched the gastrointestinal symptoms of children with autism
and the different deficiencies exhibited. Their findings indicated that children with
autism have “impairments of the primary pathway for carbohydrate digestion”
(Williams et al, 2011, page 1). This indication combined with the high percentage of
carbohydrate listed in both the meal-time observations and the school-based food
diaries would suggest a cause for concern. These children are consuming a nutrient
which Williams et al 2011 found to be difficult for autistic children to properly digest.

49 |
According to Williams et al this was due to a deficiency in “at least one of the 5
genes involved in carbohydrate digestion or transport” (Williams et al, 2011, page 3),
which was noted in 93.3% of the children they studied.
4.2) Connection to Gluten-free dietary intervention
In terms of the gluten content, 73% of the carbohydrates the researcher observed
consumed during the meal-time setting contained gluten. The remaining 27% gluten-
free carbohydrates were rice or potato products. The food diaries in Appendix.6
depict a bleak scene in relation to a gluten-free diet; 6/7 children’s school-based food
diaries contain gluten, thus showing that the majority of these children’s weekly diets
include gluten. The only child that appears to have eliminated gluten from their diet is
Child F (Appendix.6.6) however this is due to a wheat intolerance. Therefore the
child has consciously had wheat removed from their diet and the lack of gluten is
merely a by-product of this intolerance. There is no information to suggest that Child
F does not eat gluten in other aspects of his life, for example in the home setting.
From these results it can be concluded that no participants were actively following a
gluten-free diet specifically as a dietary intervention for autism. This suggests that
either the parents of these children were not aware of information regarding gluten-
free dietary intervention, or that they had actively chosen not to pursue this form of
intervention. Regardless of the reason it indicates that in this study gluten-free
dietary interventions were not a common choice amongst families of children with
autism. According to the Interactive Autism Network (IAN) 2014, an online project
involving families of children with autism in the United States found that “more than

50 |
16% of participating families are using special diets to treat their child’s autism” (IAN,
2014). Whilst the geographical factor of the IAN project differs from that of the
research within this study it still provides a comparable overview of the popularity of
dietary interventions. IAN 2014 found that diets which removed certain substances
were most common. The most frequent dietary interventions they noted were gluten-
free diets, casein-free diets or a combined GF/CF diet.
4.3) Connection to Casein-free dietary intervention
As Isherwood et al 2011 highlight, many children with autism will only eat certain
foods. “The majority of foods they will accept are gluten/casein containing foods eg:
bread and milk” (Isherwood et al, 2011, page 58). It isn’t uncommon for typically
developing children to want foods that are not as nutritionally beneficial as foods
such as fruits or vegetables, but it is easier in terms of their cognitive development to
explain why they must consume a balanced diet. For children with autism, the
cognitive and comprehensive skills needed to elicit an understanding of the
importance of balanced nutritional intake are often lacking or even non-existent.
Therefore it becomes difficult to wean them onto a diet that eliminates these foods.
Milk in particular is a food that children receive from birth therefore the connection
with milk is often very well established by the time the child is diagnosed with autism.
When looking at the data collected in the observational research, the low number of
instances of dairy consumption shown in Figure.2) would please many DAN doctors
and believers in a casein-free diet for autistic children. Figure.1) shows that only 10%
of the overall nutrient consumption was comprised of dairy products. As casein is a

51 |
milk protein it is found in most dairy products including cheese, butter, milk and
yoghurt, however according to Table 1) there were only 2 types of dairy available in
the school meal-time setting.
4.4) Case Study
The Case Study of Child X provides a vital insight into the possible success that
dietary interventions can have for children with autism. It outlines the strict regime
and lengthy process that is involved in a gluten and dairy-free diet and nutritional
supplementation as set out by a Clinical Nutritionist (CN). The findings of the case
study clearly show that changing the diet of a child with autism can have positive and
beneficial effects on the child’s behaviour, cognitive processed and socio-emotional
development. The next section will break down these effects and the results of Child
X’s dietary intervention.
4.5) Speech and Language Development
Child X had a severe language delay and was still not talking by the age of 4. The
case study shows that Child X’s first noted correct use of speech and language
appeared the day after Child X began to follow a gluten and dairy free diet. The
child’s father asked him to take a flower to his mother and utter the word “mummy”.
His compliance with this instruction proved that not only did he understand the
language used by his father; he also correctly used the word “mummy”. Although
there is no direct proof that Child X’s sudden language acquisition is linked to him
commencing the dietary intervention, it appears too much of a coincidence to

52 |
disregard it. After a complete lack of verbal communication and language skills whilst
on a normal, un-intervened diet, Child X’s dietary change appears to have been
caused by, or at least encouraged by, the removal of gluten and dairy products in his
diet.
4.6) Cognitive Development and Motor Skills
Figure.7) shows a self-portrait that Child X painted at his school. It shows that Child
X has good hand-eye coordination and motor skills and a clear comprehension of the
‘self’. The case study shows that at 2 years 10 months, Child X was demonstrating
good playing skills and the ability to climb on a climbing frame. This indicates that his
motor skills were already developing. However the case study shows that at 3 years
and 3 months he wasn’t able to ‘draw a circle’ as his fine motor skills were not yet
mature enough. Ozonoff et al 2008 conducted a study on the early development of
children later diagnosed with autism in which they found “a delay in the appearance
of motor milestones” (Ozonoff et al 2008). However, Figure.7) indicates that Child
X’s fine motor skills have progressed greatly in correlation with his dietary
intervention. Results of the intervention listed in the case study also include the
ability to ride a scooter. Not only does this involve motor skills and balance; he learnt
and understood how to use the scooter from watching his father play on it. This
demonstrates good cognitive development and maturation of motor skills. Baranek
2002 conducted a study on the efficacy of sensory and motor interventions for
autistic children. She found that “empirical evidence converges to confirm the
existence of sensory and motor difficulties for many children with autism at some
point in their early development” (Baranek, 2002, page 397). This quote supports

53 |
Child X’s initial inability to perform small tasks that require motor skills. Whilst
Baranek found some beneficial effects from motor and sensory interventions, the
case study focuses on the dietary intervention that Child X received and the positive
effects this change in diet had on his motor skills.
4.7) Limitations
It must be noted that there were limitations to this research study. Firstly, in the
observational research, the overall number of participants was not noted. This was
due to the open plan style of the dining hall which allowed the children to come and
go throughout the lunch sitting. On reflection, a head count of the children as they
entered the dining hall would have solved this issue.
A second limitation of the research was the questionnaires. Whilst they would have
provided a further contextual dimension to the research, the lack of response to the
questionnaires meant that they had to be discarded. This limitation could be
attributed to the scope of parents the questionnaire was sent to. A high percentage
of parents of children at the school used for research did not have English as a first
language therefore could not fully comprehend the questions being asked.
The final limitation of this body of work has been the vast spectrum of information
accumulated through research and the restricted word count of this study. The
researcher found that prioritisation of data and information meant that other
contextual information and interesting findings had to be omitted.

54 |
Chapter_5.0
Conclusion
In regards to the findings from the observational research and the food diaries
produced in this body of work it can be clearly determined that dietary interventions
are by no means commonly used for children with autism. The only form of restricted
diet found during this research was the removal of wheat products due to a wheat
intolerance. However, the fact that research was only conducted on one day and
results of the school-based food diaries only spanned 5 days means that the results
are restricted. There is a platform here for further research to be conducted on a
much wider scale to determine the incidence rate of dietary interventions for children
with autism.
Results from this paper found that carbohydrates, in particular refined carbohydrates,
were the most common food choice amongst children with autism and their intake
was high, yet they can have detrimental effects on the child’s body. The literature
review section explored the effects of a Candida increase in the body, which can
lead to gastro-intestinal issues including constipation and more serious effects on the
nervous and immune systems. Further study on the link between carbohydrates and
children with autism could be conducted to determine the exact (or differing) effects
of a carbohydrate rich diet on the body of an autistic child, and whether refining the
carbohydrate makes any difference.

55 |
The case study of Child-X provides a true example of the positive effects that dietary
interventions can have on a child with autism. The improvement in his speech and
language skills is remarkable; Child-X transformed from a child with a complete lack
of verbal skills to a child able to cite words and use words properly. His motor skills
also improved dramatically; initially prior to intervention Child-X couldn’t draw a
circle. Figure.7) illustrates his ability now to paint a self-portrait, using matured fine
motor skills.
Although the case study on Child-X highlights the benefits of dietary intervention for
a child with autism, it also reveals the financial impact it can have on this child’s
family. A cost of £300- £550 a month plus supplements and tests and the added
expense of buying organic, gluten free and dairy free products puts this form of
dietary intervention beyond the reach of many families with autistic children. As it is
unavailable on the NHS it makes this form of dietary intervention impossible for
families of restricted income to afford. This is an area that could particularly benefit
from further research into ways of limiting the financial strains of dietary interventions
and the accompanying lifestyle changes for children with autism and their families.
Overall, it can be concluded that intervening in the diet of a child with autism can
have a positive and beneficial effect. The case study provides evidence to support
this statement, whilst the review of literature reveals the numerous effects that
different nutrients and diets can have on these children. As the researcher intended,
an insight into the vast scope of different dietary ‘treatments’ has been provided and
the subsequent success of such ‘treatments’ has been discussed. To fully
understand the extent of the positive effects dietary interventions on autistic children

56 |
further research and a longitudinal study are imperative. The main objective of this
study however was to provide a deeper understanding of dietary interventions with
particular reference to GF/CF diets, as an informative document for anyone with a
link to autism.

57 |
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63 |
Appendices
The following pages comprise Appendix.1 to Appendix.9.
 Appendix.1- Research Checklist
 Appendix.2- Parent Information Letter
 Appendix.3- Secondary Information Letter
 Appendix.4- Consent Form (Observation)
 Appendix.5- Consent Form (Questionnaire/ Food Diary)
 Appendix.6-
6.1 Child A Food Diary
6.2 Child B Food Diary
6.3 Child C Food Diary
6.4 Child D Food Diary
6.5 Child E Food Diary
6.6 Child F Food Diary
6.7 Child G Food Diary
 Appendix.7- Child H Food Diary
 Appendix.8- Research Questionnaire
 Appendix.9- Scanned Menu Image
Chapter_7.0

64 |
Food
Group
(eg carb,
protein)
Individual
Food (eg
crisps,
chocolate)
No. of
Children
Eating This
Food
Drink (eg
water,
juice,
coke)
No. of
Children
Drinking
This Drink
Solid
Food
Blended
Food
Restricted
Diet
Appendix.1

65 |
Dear Parent/ Carer
Dietary Intervention for Children with Autism Questionnaire
Observation of Children During Meal-Time
I would like to invite you to take part in a questionnaire as part of a research project
from the School of Education at the University of Leeds. I am looking into the positive
effect that dietary interventions can have on children with Autism. The topic is
informed by the Defeat Autism Now (DAN) campaign which is a biomedical approach
to treating autism that focuses on the child’s diet. It involves various intervention
approaches ranging from removing certain ingredients from the diet, for example
yeast and gluten; and testing for hidden food allergies. My questionnaire is designed
to gather information on the typical diets that children with autism have and the food
that they eat at home. I also want to know if you are aware of the DAN campaign or
have even tried any of the dietary interventions with your children.
I would like to ask your permission also to include your child in my research. I would
like to observe your child during their lunch-time at school, to establish their attitudes
towards their food and to see which foods they generally seem to prefer. I will be
asking a few questions if appropriate on what they are eating and what foods/ drinks
they like but there will be no formal interview, only observational interaction. If you do
not give your consent for my observation, your child will be removed from any
research however if you do return the questionnaire I will still be able to use your
answers within the research project. Any information given by your child will only be
used to inform my research; I will uphold complete anonymity within my data.
I have a DBS form from the University of Leeds and 5 years’ experience working with
children with Autism and other disabilities, running holiday play-schemes for the
children where I have responsibilities such as feeding, changing, entertaining and
playing with the children. It is anticipated that this research project will shed some
light on an intervention approach that has been little researched and provide positive
results that could potentially benefit future approaches to interventions for Autism.
25/11/2013
Appendix.2

66 |
If you would like to participate in this questionnaire and agree to the use of your
answers within this research project please sign the consent form paired with this
information letter. If you have any further questions concerning this project or the
way in which your input will be used do not hesitate to contact me. In the meantime, I
thank you for any help you are able to give me. If for any reason you wish to be
removed from the research you are entitled to do so without providing a reason.
If you give consent for your child to be observed in their meal time setting and for
these observations to be used within the research project please sign the second
part of the consent form. It is not essential that you consent to both parts of this
research project; you can choose to opt out of it completely or to only consent to one
part. Complete anonymity will be upheld throughout the research and I will make the
findings accessible to you once they have been drawn up so you will be kept
informed throughout the research process. If you have any further queries please
contact Mary Chambers who will be supervising this project.
Dr Mary Chambers (M.E.Chambers@education.leeds.ac.uk)
Room G.04, School of Education (Hillary Place)
University of Leeds
LS2 9JT
0113 343 3576
Kind regards,
Louisa Pielichaty
62 Harold Terrace
Leeds
West Yorkshire
LS61LD
07799200253
Louisapielichaty@gmail.com

67 |
Dear Parent/ Carer
Dietary Intervention for Children with Autism Questionnaire/ Food Diary
I would like to invite you to take part in a questionnaire and/or a food diary as part of
a research project for my dissertation at the School of Education at the University of
Leeds. I am looking into the effect that dietary interventions can have on children
with Autism. The topic is informed by the Defeat Autism Now (DAN) campaign which
is a biomedical approach to treating autism that focuses on the child’s diet. It
involves various intervention approaches ranging from removing certain ingredients
from the diet, for example yeast and gluten; and testing children for hidden food
allergies. My questionnaire is designed to gather information on the typical diets that
children with autism have and the food that they eat at home. My food diary is
designed to gather an example of a typical week’s food and drink for your child. I
want to outline immediately that there are no right or wrong answers and that the
results of this questionnaire will be completely anonymous and that the food diary is
to be completed however you see fit.
I am also looking to find out if you are aware at all of the ‘DAN’ campaign or have
whether you have ever tried any dietary interventions with your children. I would like
to know if you have ever tried restricted diets or simply cutting out certain foods or
food groups for your children. The attached questionnaire explores this in more
detail.
I have a DBS form from the University of Leeds and 5 years’ experience working with
children with Autism and other disabilities, running holiday play-schemes for the
children where I have responsibilities such as feeding, changing, entertaining and
playing with the children. It is anticipated that this research project will shed some
light on an intervention approach that has been little researched and provide positive
results that could potentially benefit future approaches to interventions for Autism.
If you would like to participate in this questionnaire/ food diary and agree to the use
of your answers within this research project please sign the consent form paired with
02/01/2014
Appendix.3

68 |
this information letter. If you have any further questions concerning this project or the
way in which your input will be used do not hesitate to contact me. In the meantime, I
thank you for any help you are able to give me. If for any reason you wish to be
removed from the research you are entitled to do so without providing a reason.
Complete anonymity will be upheld throughout the research and I will make the
findings accessible to you once they have been drawn up so you will be kept
informed throughout the research process. If you have any further queries please
contact Mary Chambers who will be supervising this project:
Dr Mary Chambers (M.E.Chambers@education.leeds.ac.uk)
Room G.04, School of Education (Hillary Place)
University of Leeds
LS2 9JT
0113 343 3576
Kind regards,
Louisa Pielichaty
62 Harold Terrace
Leeds
West Yorkshire
LS61LD
07799200253
Ed11lp@leeds.ac.uk

69 |
Consent to Observations of my Child in Meal Time Setting
Add your initials next to the
statements you agree with
I confirm that I have read and understand the information letter
dated 25/11/2013 explaining the above research project and I
have had the opportunity to ask questions about the project.
I understand that my child’s participation is voluntary and that
they are free to withdraw at any time without giving any reason
and without there being any negative consequences. In
addition, should they not wish to answer any particular
question or questions, they are free to decline.
Contact: Louisa Pielichaty Louisapielichaty@gmail.com
07799200253
By agreeing for your child to take part in the research project
you are agreeing for data collected by the research team to be
used in publications and future research.
I consent to my child taking part in (initial all which apply):
a. every aspect of the research project including
questions during observations.
b. just observations with no questions.
I do not want my child to be involved in the research project at
all.
I give permission formembers of the research team to have access to
my child’s anonymised responses. I understand that their name will
not be linked with the research materials, and they will not be
identified or identifiable in the report or reports that result from the
research.
I understand that my child’s research responses willbe kept strictly
confidential.
I agree for the data collectedfrom my child to be used in relevant
future research.
I give permission formy answers to the questionnaire to be used to
inform the research project. I understand that my name willnot be
linked with the research materials, and I will not be identified or
identifiable in the report or reports that result from the research. I
understand that my research responses will be kept strictly
confidential.
By agreeing to take part in the research project I am agreeing
for data collected by the research team to be used in
publications and future research.
I do not wish to be part of this research project and will not be
Appendix.4

70 |
returning the questionnaire.
Consent to take part in Meal-Time Observations and
Questionnaire
Name of parent / carer
Parent / carer’s
signature
Date
Name of lead
researcher
Louisa Pielichaty
Signature
Date*

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