Oral Motor/ Sensory History:
By parent report, Jonathan is an “extremely picky eater.” He only eats : macaroni and cheese, grilled cheese, Eggo frozen plain waffles (dry), store brand frozen pizza, one brand of chicken nuggets, a homemade fruit smoothie (specific to almond milk, banana and strawberry), almond milk, water, potato chips, and graham crackers. He will not tolerate new brands or any small changes in the presentation of these foods. For example, he eats the frozen “square” pizza, but will not eat a slice of pizza in a restaurant. He never sucked his thumb or used a pacifier. He weaned from the bottle at 13 months old, but did use a sippy cup for more than 3 to 6 months. He can drink from a straw. He grinds his teeth when excited. He has a history of being sensitive to sounds. He is right handed. He sleeps from 6:30 PM to 7:00 AM. He naps on weekends. He is verbal, but only intelligible 50% of the time. He understands most of what is said to him.

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Social History:
Jonathan was described as a “pleasant, happy child.” He smiles and greets others. He is quiet with new people and needs to be prompted to say “Hi.” He wants to play with other children, but it is hard for others to understand him. He enjoys playing with play dough, riding his bike, swimming, matching games and puzzles. He has an average activity level and likes to be outside and playing.

 

Testing Observations:
Jonathan entered the clinic with his mother willingly. He had a tantrum when he was asked to stop playing with the blocks and move into the chair for work. His mother reported he has not had these behaviors in quite some time, and it was thought to be due to the presence of food in the room for the assessment. He transitioned to the chair when his behavior was ignored. His mother also employed ABA strategies throughout the testing to regulate his behavior, such as using her iPhone as a timer, and setting clear expectations. His father came to the assessment a bit later and Jonathan’s behavior improved in his presence.

 

Jonathan exhibited several preservative behaviors such as the need to complete a building task and to clean up all items before sitting down. Jonathan spoke in sentences throughout, but his responses at times seemed rehearsed or memorized as opposed to spontaneous. Never the less he was able to answer most questions and keep up with the conversation. He had several anxieties, one being the fear of flushing toilets. When he needed to go to the bathroom he would not go with his mother but quickly agreed to go with his father because he thought there will be urinals as opposed to a regular toilet. When upset he would talk about returning to the minivan and going home. He seemed to have his own strategies to self-sooth which help him engage in therapeutic activities.

 

After a thorough assessment the following summary, diagnosis, and recommendations were made:

 

Summary:
Jonathan was a 3 year, 1 month old male who recently started a preschool program and had a diagnosis of Mild Autism Spectrum Disorder. He has done very well in ABA and in therapies, but has issues with speech clarity and feeding which prompted this evaluation.

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Jonathan had some strengths including: adequate orofacial tone for speech and feeding, positive self-regulation skills even when upset, positive social interaction with the examiner and recent language expansion. Areas of weakness noted in this assessment included: limited lingual mobility, tongue thrusting, and motor planning deficits. Jonathan fixed his jaw in a high posture and often had retracted lips which impaired his overall clarity and resonance.

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Feeding issues were the result of a breakdown in the sensory-motor system. One cannot separate one from the other. He had difficulties with latching at birth and this is directly related to the possibility of a restricted lingual frenulum. If a child has reduced lingual mobility this also impacts the ability to handle the bolus when solids are first introduced. Between structural, sensory-motor issues and behavioral challenges associated with ASD, it is not surprising that he has a self-limited diet. Jonathan also met the criteria for Childhood Apraxia of Speech based on his inability to execute non-speech oral postures, blow on command and imitate oral postures. He also presented with atypical and erratic speech sound errors that have not responded to traditional therapy methods.

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Jonathan would benefit from a speech therapy treatment protocol that addresses both his feeding and speech issues.

 

Diagnostic Impressions:
(784.69) Childhood Apraxia of Speech
(783.3) Feeding Mismanagement
(750.0) Rule Out Ankyloglossia (tongue-tie)

 

Recommendations:

• Oral Placement/Feeding/PROMPT therapy by a speech pathologist with post graduate training in oral sensory-motor and feeding disorders.​

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• Parents will need training to implement carryover in the home. The home ABA team is also welcome to help with this program.

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• ENT evaluation to entertain the possibility of Ankyloglossia (tongue-tie) secondary to limited lingual mobility. Referrals were given to the parents during the assessment.

 

This case study highlights a few key points when assessing feeding issues in children with ASD. First, there can be concurrent structural issues. This was seen in Jonathan’s case, as the lactation specialist may have missed the possibility of a tongue tie when latching issues occurred. Second, just because a child has a diagnosis of autism does not automatically imply that the feeding issues are purely behavioral. Consider that feeding mismanagement often starts in infancy long before the autism diagnosis (Gillberg, Nordin & Ehlers, 1996). Finally, global sensory-motor issues can spill over into feeding issues. In Jonathan’s case, his sensitivities to sound, and perseverations clearly were reflected in his eating habits.  For example, sensitivity to sounds in the environment impacted his comfort level and subsequently reduced his food intake.

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In clinical practice the speech-language pathologist needs to look at how the child with ASD reacts to touch of the extremities, the face, and oral cavity as well as oral habits such as teeth grinding, mouthing objects, and eating items other than foods (Pica). A diet analysis is needed to assess if the child has intolerances to certain tastes, temperatures and textures. This will establish the child's home base and provide a starting point for diet expansion. The therapist must look at the underlying oral sensory-motor skills to support safe, effective nutritive feeding.

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3- Biomedical Treatments:

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Biomedical treatments are becoming more popular within the ASD community. Since these treatments often involve the diet, the evaluating and/or treating therapist should also be aware of diet restrictions and supplement therapies with which the client is involved. Many of the clients with whom an SLP comes in contact are now on these specialized diets (Defeat Autism Now, 2013).

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The Defeat Autism Now (DAN) protocol believes that human genetics haven’t changed over the years. What has changed are environmental factors, including the increasing number of chemicals to which  we are exposed from pesticides, flame retardants, plasticizers, solvents, personal care products, medicines, artificial sweeteners, and flavors. These varied factors may have an impact on the expression of our genes. This coincides with the theory of epigenetics of ASD, in which it appears that autism often results from a combination of genetic susceptibility and environmental triggers (Haliday, 2014). The way these environmental factors impact one person may be different than the way they are expressed in another person even if two people are related (Magaziner Center for Wellness, 2014). It is believed that many children with autism have a defect in their ability to excrete certain chemicals; therefore, they were more genetically susceptible to chemicals’ effects.

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The DAN philosophy is very centered on the gut-brain connection. This theory supports that toxins in the gut can greatly impact the brain and certain substances such as gluten (wheat protein) and casein (milk protein), are triggers that negatively impact functions of the brain and increase undesirable behaviors in children with ASD. Therefore, according to the DAN protocol, gluten and casein should always be removed from the diets of children on the autism spectrum (Bock, 2011). Beyond that, there may be additional foods that the child is sensitive to, that require elimination.

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The DAN protocol also involves diagnosis and treatment of the gastrointestinal system, treatment of immune system abnormalities, assessment of possible metabolic and genetic abnormalities, and nutrition treatment (Pangborn & Baker, 2005). Suggestions by DAN Physicians may include:

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• Nutritional supplements including certain vitamins, minerals, amino acids, and essential fatty acids

• Testing for hidden food allergies and avoidance of allergenic foods

• Treatment of intestinal bacterial/yeast overgrowth (with pro-biotics, supplements and other non-pharmaceutical medications)

• Detoxification of heavy metals through chelation, a potentially hazardous medical procedure (Willingham, 2012).

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While the DAN protocol is commonly known there other biomedical protocols which may be considered controversial, yet antidotal evidence and parent feedback have raised more awareness of alternative treatment methods in the field of biomedical approaches. For example, Stan Kurtz developed the therapeutic use of Valtrex and methylcobalamin (mB12, methyl B12) that reportedly has helped children with autism when other therapies did not.  Valtrex is related to acyclovir and has shown efficacy against many but not all strains of some herpes viruses, including HSV1, HSV2, and VZV (chickenpox), with lesser degrees of effectiveness against Epstein Barr Virus, HHV6, and possibly Cytomegalovirus. The use of Valtrex is based on the theory that children with autism have high titers of these viruses (Autism Society of Larimer County, 2008).

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Dr. Michael Goldberg, an autism specialist, argues that ASD is actually a neuro-immune disorder, as opposed to being a psychological or a genetic one (Goldberg, 2011). His treatment is a five- step process that considers possible stresses on the neuro-immune system including: food intolerances, respiratory allergies, activated viruses, and overgrowths of bacteria or yeast. Step one includes an evaluation and workup. Step two involves allergy testing to assess food intolerances and triggers in the diet. Step three targets immune stressors such as yeast overgrowth. Step four looks at the brain through a Nuero Single Photon-Emission Computed Tomography (NeuroSPECT) scan and considers blood flow and the need for Selective Serotonin Reuptake Inhibitors (SSRIs) to restore the correct balance needed for proper neural functioning. Step five involves rehabilitative therapies to work toward recovery. (Goldberg, 2010-2014).

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Nutritional supplements are very much a part of biomedical interventions. While speech-language pathologists should not be taking the lead in these biomedical treatments, professionals in our field may be asked to assist with diet conversion, and supplement administration, as well as for professional opinions on these treatments. It is always important to follow the American Speech-Language Hearing Association (ASHA) Code of Ethics in regard to evidenced-based practices, and to be familiar with the latest research available when becoming involved with biomedical protocols. It is not within the scope of practice of an SLP to offer medical advice. We can however, refer to the appropriate specialist when warranted and present the latest research on this information.

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For example, the Nourishlife Speakâ„¢ supplemental has been widely controversial amongst biomedical professionals. While originally developed to help apraxia of speech, many parents of children with ASD children started using this supplemental with their non-verbal children. A widely published letter from the Food and Drug Administration cited three issues with Speakâ„¢ (Schneeman, 2013):

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• First, the supplement is being marketed as a treatment for childhood speech delays, such as apraxia, without proper approval by the FDA and without proper substantiation.

• Second, Speak’s labeling contains false and misleading claims and does not have adequate instructions for use or warnings.

• Third, the amount of vitamin E contained in Speak far exceeds the tolerable upper intake level set by the Food and Nutrition Board, and may be hazardous to the health of children.

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Therapists need to be educated on biomedical theories because when families and their physicians are implementing a biomedical protocol, SLPs may need to consider those parameters as part of a feeding program. Biomedical theories support the concept that self-limited diets can be more than just a behavior, because biomedical interventionists look at the whole child and issues with the gut-brain connection. Behaviors, including self-limited diets, are treated holistically and not just with behavior modification (Bock, 2011).

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4 - Applied Behavioral Analysis:

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Consideration of a child’s sensory-motor and medical issues is necessary; however, Applied Behavioral Analysis (ABA) is very useful. ABA is a method of behavioral intervention developed by Ivan Lovaas PhD and Tristan Smith PhD (Lovaas & Smith 1989; Cure Autism Now, 2005). It consists of teaching skills by breaking them down into small steps, while rewarding the correct responses. It is data driven and quite intensive. ABA is often associated with Discrete Trial Teaching (DTT) which uses instruction-prompt-response-reward to help children with ASD complete complex tasks. The principles of ABA can be successful in feeding therapy sessions (Volkert & M Vaz, 2010), as long as pre-feeding and feeding skills are task analyzed and appropriate food choices are made based on a child’s “home base” (Overland & Merkel-Walsh, 2013). Positive reinforcers, as well as restoring the “joy of eating”, can be automatically reinforcing to a child, if the right food choices are selected to present. Random food choices or advancing textures too quickly can result in negative food experiences. By changing foods by only one element at a time, children can expand their diet slowly and successfully.

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An example of this procedure was used in Case Study #2:

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Daniel was a three year old male with ASD. When he came to the clinic he was only eating a few select purees. Any progression in taste or texture led to emesis. He was previously assessed by a local feeding clinic, as well as a gastroenterologist and dietician. Modified Barium Swallow Study ruled out dysphagia. Upper endoscopy ruled out esophageal dysfunction, but proved positive for mild gastroesophageal reflux disease (GERD). Blood samples proved positive for a mild dairy allergy, which was thought to be linked to his reflux issues.

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The initial assessment revealed that Daniel did not have adequate control of a pureed bolus. When a spoon was presented to the lips, he raked the puree off of the spoon and used tongue protrusion in an immature pattern to swallow the bolus. When the examiner attempted to present that same puree to the lateral margins of his tongue he immediately began to gag and his eyes started to water. He kept repeating the words “all done.” Lateral tongue movements were absent. He was not able to compress a Chewy Tube®. Daniel did not have the pre-feeding skills to handle advanced textures, and previous attempts at feedings resulted in gagging and vomiting. These reactions are now habitual anytime he feels a bolus in an area of the mouth that he feels he cannot clear.

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Daniel was placed on an intense pre-feeding therapy plan, working on normalizing the oral cavity beginning with the facial area and working from his lips into his mouth. He learned to tolerate non-food stimulation such as a vibrating therapy tool on the lateral margins of the tongue. Jaw strength, lip closure, and tongue lateralization were target goals.

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As his pre-feeding skills improved, his accepted purees were added to his treatment plan. This included: side spoon feeding to improve lip closure and syringe feeding to improve tongue lateralization. In addition pre-feeding mastication programs began with the use of “The Chewing Hierarchy” developed by Lori L. Overland. Daniel began to improve jaw strength and developed a munch chew.

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Daniel’s ABA therapist helped with the success of the therapy sessions. He was placed on a fixed ratio reinforcement schedule to increase positive behaviors. First, Daniel received reinforcement for every attempt at a sensory-motor task, or with the acceptance of the pureed food. As time progressed and his refusals decreased, Daniel could work with the therapist for longer intervals. If Daniel refused the task, he was ignored for 5 seconds, and then the task was represented with the positive reinforcer present. He usually chose small figurines to hold, or timed breaks with the iPad.

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As his sensory-motor skills for feeding improved, Daniel’s anxiety surrounding feedings started to lessen. He was open to the acceptance of a variety of pureed foods and started to accept crushed cookies and crackers in his mouth with a Zvibe, a vibrating oral-sensory tool. The activities themselves became rewarding, and he needed less tangible reinforcers throughout the sessions. He started to accept the combination of textures and various flavors, which eventually led to tasting small bites of easy to melt solids such as Gerber® Puffs, cheese puffs, toddler snacks and small pieces of canned fruit. He is currently working on accepting more solids into the diet.

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Daniel’s case study is just one example of sensory- based diet shaping, within an ABA context. Diet-shaping requires the therapist to look at temperature, texture and taste. Changing these elements in regimented, sequential steps may expand the diet. In addition following an ABA program, on a fixed ratio schedule, can also help with progress (Brophy, 2013).

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To properly utilize diet-shaping in an ABA context, the therapist should be careful to only change one element at a time. For example, by chilling or freezing fruits, the textures also changes. By mixing foods together, the therapist is changing taste and texture simultaneously and this may be too much for a child with ASD to handle. Many parents will try to “hide” a new food in a preferred food only to find that this causes a major regression in a child’s diet. Children with sensory processing issues can be quite sensitive, and will not be easily fooled by trying to “disguise” new foods.

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The following are examples of diet shaping: