1. Autistic Spectrum Disorders are the result of a Bowel Disorder?

2. Diagnostic Problems. n Multiple Diagnostic ‘Criteria’ n Overlap with Attention Deficit, Dyspraxia and Dyslexia. n Children with severe Global Developmental delay. n The role of Genetic Factors – specific Chromosome Disorders and less specific genetic factors.

3. Patterns of Presentation. n Features from early infancy. n Plateauing of Development. n Regression, particularly in second year of Life.

4. Features of Regressive Pattern n Clear evidence of normal development in first year. n High incidence of allergic disorders in child and family. n Probable increased frequency of Low IgA. n Frequent Upper Respiratory infections in the first year of life.

5. Features of Regressive Pattern n Frequent incidence of bowel symptoms - ?finding of lymphoid nodular hypoplasia. n History of frequent use of antibiotics in first year of life.

6. Preliminary Review 1997-99.

7. 57 Cases. n Age Range: 2-15 years. n Mean Age 4 years 1 mont. n Number with regression 35. n Average age of regression 16 months. n Bowel symptoms : 36 n Excessive Thirst: 33

8. Recommended Treatment. n None13 n Anti-fungal24 n Gluten/Casein Free9 n Anti-fungal & Gluten/Casein Free Diet. 11.

9. Outcomes. n Definite and sustained improvement28 (15 reporting deterioration when intervention discontinued). n Uncertain improvement.6

10. A Review of Children referred for Consideration of Dietary Management for the Autistic Continuum. 2001. Dr. Clive Jones.

11. Pattern of referrals reviewed.

12. Pattern of Symptoms.

13. Comorbidity n 1 child previously diagnosed as Coeliac. n 1 child previously diagnosed as ?Gluten enteropathy. n 1 child suffered myoclonic seizures.

14. Associated Symptoms. Bowel Problems 44 (64%).

15. Allergic Features. 43 (62%).

16. Combination of allergy / bowel symptoms. n Number with >1 allergic feature22 n Number with >2 allergic features11 n Number with allergic features and bowel symptoms.22 (38%). n Number who had either bowel or allergic features.58(84%).

17. ‘Soft Symptoms’

18. Other features. n 5 had a history of diarrhoea after ingestion of soya. n 13 had a history of food cravings or dislikes. n 11 had evidence of prior fungal infection. n 30 had a history of prior antibiotic therapy.

19. Clinical Findings.

20. Family History

21. Prior Management n 22 had had urinalysis at University of Sunderland. 9 positive for casomorphine and 5 for glutamorphine. n 41 had tried gluten free/casein free diet to some degree, often without adequate support. Many reported improvement with this, especially with casein free diet, those who reported improvement generally reported initial regression.

22. Prior Management n Many were on a complex mixture of other supplements, interventions including DMG. Some had tried secretin (real or homoeopathic without clear benefit). n 10 were on an educational type intervention - 7 using LOVAAS & 3 ABA.

23. Interventions recommended. n A preliminary assessment of likelihood of responding to nutritional interventions. n A review of the current interventions, including supplements and the nutritional adequacy of the diet being followed. n Low sugar/low yeast diet with nystatin in 40 Gluten Free/Casein Free diet in 5.

24. Nystatin Therapy. n Effectiveness of nystatin in polysymptomatic patients. A randomized, double-blind trial with nystatin versus placebo in general practice. Heiko Santelmann, Even Laerum, Joergen Roennevig and Hans E Fagertun. Family Practice, Vol.18, No. 3. 258-265.

25. Response to treatment. n Almost all children reacted to the introduction of nystatin with an increase in symptoms, most requiring subsequent titration of the dose to see optimum improvement. (This is a reaction not generally seen when children or adults are treated with nystatin).

26. Response to Treatment. n Data on 13 children treated with nystatin followed through for at least 6 months. n 8M & 3F appeared to exhibit very positive responses in both autistic and associated symptoms - usually substantiated by reports from other professionals. n Average age of this group at inital consultation was 4.1 years. (Range 2.5-7.2)

27. Conclusions. n In addition to earlier reports these data indicate a potential for managing some children in the autistic continuum with diet and or anti-fungal treatment. There is clearly a need for further prospective studies, however there will be considerable problems in arranging these on a double blind basis.

28. Conclusions. n This data has further refined the clinical criteria that should be used to identify children to be entered into such a study. n The clinical input appears to have helped some parents to recognise that dietary approaches were unlikely to be helpful for their own child, and thereby helped to rationalise prior interventions.

29. The Way Ahead? n A Double Blind Placebo Controlled Trial of Nystatin in a specific sub-group of patients. (MRC has recognised a need for research into Bowel disorders and bowel flora and autistic spectrum disorders). n In the interim follow the principal of sequential intervention and ensure that any changes do not cause more problems.