I. Clinical Question Is gluten free and casein free diet effective in improving the behaviour of an autistic child? II.

Citation Article 1 Nazni, P, et al. Impact of Casein and Gluten Free Dietary Intervention on Selected Autistic Children. Iranian Journal of Pediatrics, (2008), DOI: pe08038 Article 2 Pennesi, C, et al. Effectiveness of the gluten-free, casein-free diet for children diagnosed with autism spectrum disorder: Based on parental report. Nutritional Neuroscience (2012), doi: 10.1179/1476830512Y.0000000003 Article 3 Johnson, C, et al. Effects of Gluten Free / Casein Free Diet in Young Children with Autism: A Pilot Study. Journal of Developmental & Physical Disabilities (2011), DOI 10.1007/s10882-010-9217-x Article 4 Mulloy, A, et al. Gluten-free and casein-free diets in the treatment of autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders (2009), doi:10.1016/j.rasd.2009.10.008 Article 5 Hyman S, Stewart P, Smith T, et al.: The Gluten Free and Casein Free Diet in Young Children with Autism. Golisano Childrens Hospital, University of Rochester Medical Center. Presented May 22, 2010 at the International Meeting for Autism Research, Philadelphia. www.urmc.rochester.edu/news. III. Study Characteristics a. Patients Included A.1 The study is composed of a total number of 50 autistic children. The subjects are divided into three groups and the Group 1 is composed of 10 children, the Group 2 is composed of 10 children and lastly the Group 3 is composed of 30 children. The subjects are selected from a three private special schools in a Salem District, Tamilnadu, India. The 10 children are from SIMEC, 10 children are from MMIC and the other 30 children are from CSI. A.2 The participants of the study are the parents or primary caregivers of children diagnosed with autism. The participants are recruited thru e-mail listservs, various autism organization and thru one on one interview with the parents of the children with autism.

Four hundred and forty-eight participants attempted to finish the study but only three hundred and eighty-seven of the participants were able to finish and complete the study. A.3 The study is composed of a total number of 22 preschool subjects with autism and they were able to finish the study. Among the 22 subjects, 8 of them were assigned to the gluten and casein free diet while the rest of the sample were assigned to the healthy diet and low sugar diet. A.4 The study is composed of a total number of 188 participants. Most of the participants were male. According to the study the participants were diagnosed with autism (93%) and Asperger syndrome. Participants ranged from 2 to 17 years of age. A.5 The study is composed of 22 children with ASD between ages 2 and 5 years old. The children were each receiving at least 10 hours/week of early intensive behavioural intervention (EIBI), with no other interventions or drug treatments. b. Intervention Compared B.1 The research study is designed to test the effectiveness of dietary intervention specifically the gluten and casein free diet in changing the behavior of an autistic child. The group 1 was under the casein free diet and they are prohibited to consume products with casein. The group 2 was under the gluten free diet and they are prohibited to take foods with gluten. The last group was under the gluten free and casein free diet and they were also prohibited to intake foods with casein and gluten. The study explains that foods with gluten and casein contain opioid peptide which causes autistic symptoms. B.2 This study is done to test the effectiveness of gluten and casein free diet among those children with autism. There are 2 groups in the study. The first group eliminated all the foods with casein and gluten. The second group was not able to eliminate those foods with casein and gluten. The parents are B.3 The study is designed to compare the effectiveness of gluten free and casein free diet and healthy, low sugar diet in improving the behavior of an autistic child. The participants are divided into groups. The first groups were under the gluten and casein free diet and the second group were under the healthy, low sugar diet. B.4 The intervention compared to the study is the casein free diet, gluten free diet, and both casein free and gluten free diet. This is to test if what diet has the greatest impact in improving the behavior of an autistic child.

B.5 There is no intervention compared in the study. Based from the study they used the dietary intervention in up to one third of children with autism. c. Outcome Monitored C.1 Based from the article they selected three private special schools in Salem District, Tamilnadu, India were selected. A total number of 50 autistic children 10 from SIMEC, 10 from MMIC and 30 from CSI comprised the study sample. Background information, clinical history and nutritional status, dietary pattern were collected from the 50 selected autistic children. Out of 50 autistic children 30 autistic children were selected for the dietary intervention. Diet counselling regarding casein free diet was imparted to Group I (n=10), gluten free diet to Group II (n=10) and both casein and gluten free diet for Group III (n=10). The diet was followed for a period of 2 months. The efficacy of the dietary exclusion of casein and gluten was evaluated using a food and behaviour diary on a day to day basis, using observation method. The data was compiled and analyzed by using statistical methods. Descriptive statistics and paired comparison test are computed using statistical software SPSS version 14.0 determines the significant differences between the diets. C.2 The study analyzes parental report data collected using a 90-item online questionnaire from 387 parents or primary caregivers of children diagnosed with Autism Spectrum Disease (ASD) on the efficacy of the GFCF diet. Parents reported on their childs GI symptoms, food allergy diagnoses, and suspected food sensitivities, as well as the degree and length of their diet implementation. C.3 Based from the article, the pilot study involved a three-month, prospective, open label, randomized, parallel groups design of a GFCF diet compared to a healthy, low sugar diet (attention control) for young children with ASD. Both treatment groups evidenced some gains across a range of variables, including measures of behavior, language, and ratings of the core features of ASD. C.4 Based from the article, the review involved a systematic analysis of studies that focused on the treatment of Autism Spectrum Disease (ASD) with Gluten Free Casein Free (GFCF) diets. Each identified study that met pre-determined inclusion criteria was analyzed and summarized in terms of (a) participants, (b) specifics of the intervention, (c) results, and (d) certainty of evidence. To assess the certainty of evidence we critically appraised each studys design and related methodological details. Given our aim to review all available studies, and the fact that the studies used various and inconsistent research methodologies, our review approach is dominantly narrative, and when possible, quantitative.

C.5 According to the study analyses are based on 14 children (12 boys; mean age 43.5 months) who maintained the GFCF diet for the 12-week duration. The group displayed no statistically significant change in parent/teacher/ researcher scores of attention or activity; frequency or quality of stools; sleep behavior; or actigraphy (activity levels) on either the baseline/diet comparison or on the pre-/post snack comparisons. d. Does the study focus on a significant problem in clinical practices? Yes, the study focuses on a significant problem especially in the clinical practice since autism is a lifelong developmental disorder that emerges in early childhood and results in significant lifelong disability. It is for us to help them in their everyday life and help them improve their behaviours. IV. Methodology/Design a. Methodology A.1 The goal of treatment is to promote the childs social and language development and minimize behaviors that interfere with the childs functioning and learning. This study evaluated the impact of casein and gluten free diet among selected autistic children using an observation method. A.2 The study included eligible parents/primary caregivers that had the opportunity to complete an online survey for all of their children who were diagnosed with an ASD. If desired, participants were able to leave and return to survey from the same computer over the course of the day. Data were collected over a 5-month period of time. A.3 Based from the article, the study was approved by the University of Pittsburgh Institutional Review Board and all families signed study consent prior to participation. Diagnoses were established by conducting the Autism Diagnostic Observation Schedule and confirmation via DSM-IV criteria for an ASD. Participants were recruited from a child developmental assessment clinic located in a metropolitan area, through area developmental preschool programs, as well as via advertising in local Autism Newsletters and websites. A.4 Based from the article, to be included in this review, the study had to meet three inclusion criteria. First, a study had to contain at least one person with an ASD, including autism, Asperger syndrome, or pervasive developmental disorder, not otherwise specified (PDD-NOS). Second, the intervention being investigated had to involve a diet that removed or reduced the consumption of gluten and/or casein. Finally, the dependent

variable had to be in some way related to the amelioration of ASD symptoms, for example, improved communication, or emotional reciprocity. Studies were excluded if they (a) summarized intervention research, but did not conduct a diet manipulation, (b) if procedures were implemented without oversight or direction from researchers and, if the only measured outcomes were unrelated to autism symptoms. A.5 The children involved in the study were maintained on the GFCF diet over a 12week period, during which each child received weekly, randomized, double-blind challenges snacks containing either 20 grams of wheat flour, 23 grams of non-fat milk, both, or neither. Each type of snack was given three times. The snacks were identical in appearance and as similar as possible in taste and texture, so that the child, the family, and the observing researcher were blinded to their content. b. Design B.1 B.2 The study used the observation method as their research design. The parental report used the experimental research design in their study.

B.3 The pilot study involved a three-month, prospective, open label, randomized, parallel groups design in their research. B.4 The review involved a systematic analysis of studies that focused on the treatment of ASD with GFCF diets. B.5 The design used in the study is the double blind trial to control carefully for other interventions. c. Setting C.1 The study was undertaken at the Tamil Nadu State Council for Science and Technology (TNSCST), Chennai, Salem District, Tamilnadu, India. C.2 The study was undertaken at the Department of Biobehavioral Health, The Pennsylvania State University, PA, USA. C.3 The study was undertaken at the Childrens Hospital of Pittsburgh, Autism Center, University of Pittsburgh School of Medicine. C.4 The study was undertaken at the Department of Special Education, 1 University Station D5300, The University of Texas at Austin, Austin, TX 78712, United States.

C.5 The study was undertaken at the Golisano Childrens Hospital, University of Rochester Medical Center. d. Data sources D.1 The data gathered in the study are all primary sources since the respondents are the one who provided the data needed in the study. The data collected from the respondents are the the dietary pattern of the subjects. D.2 The data used in the study are all from primary sources. The parents or the primary caregivers of the autistic child is the one who provided the information needed. D.3 The data sources are all primary sources because the parents of the involved respondents are the one who provided the information needed in the study thru recording the behaviour of thier child. D.4 The data used in the sudy are from secondary sources since they used informations from the related literatures of the studies regarding casein and gluten free diet for autistic child. D.5 The data gathered in the study are from primary sources and at the same time from secondary sources. The primary source are the parents of the autistic child while the secodary sources are the teachers and research assistants. e. Has the original study been replicated? E.1-E.5 No, all of the original study has not been replicated. f. What are the risk and benefit of the nursing actions/ interventions tested in the study? F.1-F.5 There are no known risk found in the study since the conducted research studies is approved by various instituions that allow them to perform the study and the researchers considered the safety of the participants involved in the studies. They also considered the ethical issues in conducting a study and since their participants are human. In line with the benefits of the nursing interventions given to the participants it showed that it is effective in improving their behaviour. V. Result Study

Based from the five article that I have read it shows that casein and gluten free diet is effective in improving the behavior of an autistic child. Out of five, three of the study have positvely confirmed the effect of casein and gluten that when elimated it is helpful in improving the behavior of an autistic child. It improves the attention span of the child, the hours of sleep of the child, it also affect the hyperactivity and anxietly level of the child. It shows that it is more effective whe both casein and gluten foods are eliminated from the diet of the child. Two of the study showed that it is not effective in improving the behaviour of the autistic child. VI. Authors Conclusion/Recommendation a. What contribution to the clients health status do the nursing action/ intervention make? The contribution of the nursing intervention to the health status of the client is the improvement of the behaviour the autistic child. It showed to the studies that casein free and gluten free diet is essential in changing the bahaviour of an autistic child in terms of attention, sleep, hyperactivity, and anxiety or compulsion. b. What overall contribution to nursing knowledge does this study make? The overall contribution of the study to nursing knowledge is to find more alternatives in improving the behaviour of an autistic child that is readily available in the market that is easily accesible for them. It also inform us that diet is an important aspect that we need to focus with in the child with autism because it has a great impact to them. VII. Applicability a. Does the study provide direct enough answer to your clinical question in terms of type of subject intervention and outcome? Yes, it has a direct answer to the clinical questions because the study shows that there are enough participants that could participate in the study. The intervention they used in the study could be easily adopted by the participants as well as the parents or primary care givers of the autistic child and they could easily find foods that are casein and gluten free. Most of the studies regarding casein free and gluten free diet is positive in improving the behavior of an autistic child. b. Is it feasible to carry out the nursing action in the world?

Yes, it is feasible to carry out the nursing action in the world since foods that are casein free and gluten free are readily available in the market ang there are enough supply of foods that are casein free and gluten free. VIII. Reviewers Conclusion According to wikipedia.org autism is a a disorder of neural development characterized by impaired social interaction and communication, and by restricted and repetitive behavior. The study regarding the casein and gluten free diet for autistic child is a impormative study because it ables us to know alternative intervention in improving the behavior of an autistic child. Based from the study it is an inervention that they could adopted and implement easily and help them develop their behaviour. Thru the newly found intervention it is a great help for them to experience a normal life and perform their activities of daily living without any difficulities. This study may help not only the people afflicted but also the health care institutions in discovering a more accessible and effective way in improving the behaviour of an autistic child. It is also a great help to those parents with autistic child because they could adopted the casein free and gluten free diet to their child and see if it is effective to their child in improving their behaviour. IX. Evaluating Nursing Care Practices a. Safety The study uses the dietary intervention and they used the casein and gluten free diet to autistic children and it is for them to know if it is effective in improving their behavior. The study is safe since the research study done to them are approved by various instructions and before they started the study they make sure that the participants will not be harm and they considered their safety. They also conducted medical test before they perform the test to them. b. Competence of the care provide The research considered the competence of the care provided because they make sure that before the give the intervention they know the possible side effects in giving the casein and gluten free foods. The participants are also allowed to choose if they want to finish the study of not. The parents of the participants were educated about the study and they were thought on how to give the casein and gluten free diet. c. Acceptability

The research that has been done is acceptable because the researchers were approved by different instutions that were handling autistic child. The study is also acceptable because there are enough participants that were willingly voluntreed in the study that were conducted to them. d. Effectiveness The research study wants to know the effectiveness of the casein free and gluten free diet in improving the behaviour of the austic children. Based from the results of the studies it showed that majority of the conducted research regarding the effectiveness of casein and gluten free diet is positive in improving the behaviour of an autistic child. Thefore the study done to the autistic children id effective. e. Appropriateness The research study is appropriare because they have enough sources that they could use in the study and they also have enough respondents. The intervention the used is reliable since they tested first if there are possible side effects that the could get into it if the consume foods that are casein and gluten free. The study is also appropriate since the intervention that they used is effective in improving the bahaviour of an autistic child. f. Efficiency The research study that have been conducted is efficient since they could buy foods that are casein free and gluten free in the market and it is also ready available and they have enough supply that they could use. The study is also efficient since the participants included in the study could still continue to eat the foods in their own house since their parents or primary caregivers are educated on how to give the foods that have been prescribed to them.

FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING
Nicanor Reyes St. Sampaloc, Manila

Evidence Based Nursing

Submitted by:
ALBANO, CHRISTIAN DALE C. BSN402

Submitted to:
Dr. Lyra Blanco
Clinical Instructor

April 26, 2013