Schechtman2007L.pdf

PSYCHIATRIC ANNALS 37:9 | SEPTEMBER 2007 639

C M E

A
utism spectrum disorders
(ASD) are among the most
puzzling forms of develop-

mental disability. This term refers to
a spectrum of pervasive developmen-
tal disorders sharing defi cits in three
major domains: social relatedness and
interactivity, communication, and re-
stricted interests and/or stereotypic or
repetitive behaviors with diffi cult tran-
sitions. Studies have investigated ge-
netic factors, neurologic, immunologic,

Scientifi cally Unsupported Therapies
in the Treatment of Young Children with

Autism Spectrum Disorders
Merryl A. Schechtman, MD

1. Identify the domains of comple-
mentary and alternative therapy.

2. Describe the basis for the brain-gut
connection hypothesis in autism
spectrum disorders.

3. Discuss sensory issues in children
with autism and sensory integra-
tion therapy.

Merryl A. Schechtman, MD, is Assistant

Clinical Professor of Pediatrics, Albert Ein-

stein College of Medicine, Infant Preschool

Unit, Children’s Evaluation and Rehabili-

tation Center, Rose F. Kennedy Center.

Address correspondence to: Merryl A.

Schechtman, MD, 1410 Pelham Parkway

South, Bronx, New York 10461; fax 718-

892-2296.

Dr. Schechtman has disclosed no rel-

evant fi nancial relationships.

EDUCATIONAL OBJECTIVESC M E

©
2

00
7/

Ju
pi

te
r

Im
ag

es
/C

or
bi

s

3709Schechtman.indd 6393709Schechtman.indd 639 8/30/2007 10:09:46 AM8/30/2007 10:09:46 AM

640 PSYCHIATRIC ANNALS 37:9 | SEPTEMBER 2007

and early environmental
insults. ASD are lifelong,
often severe disorders
impacting all facets of
individual, family, and
community function. Re-
lationships are disrupted,
and socially inappropri-
ate behaviors are promi-
nent. Often these children
do not cope well with
change, making it diffi –
cult for families to go out
in public places. Children may become
aggressive, self-injurious, or resort to
self-stimulatory behaviors, which serve
to calm them. Although the underlying
causes of ASD have not been clarifi ed,
several promising interventions have
been developed utilizing behavioral
techniques, educational programs, and
pharmacotherapy to address the symp-
toms of this disorder. The prognosis for
truly normal function is guarded, even
with availability of standard therapies,
a factor often leading to parental des-
peration and the willingness to invest
in newer approaches to treatment. Ef-
fective evidence-based services may
also not be available or in short supply.
Standard therapies may require much
time to see progress, and therefore
some parents may be willing to grasp at
the promise of a “quick fi x.”

Scientifi cally unsupported therapies
lack a foundation based on objective,
controlled research, using methods
standardized within biological or medi-
cal science. Therapies such as these are
often used either in conjunction with
evidence-based medical treatments
(complementary therapies) or might be
used instead of the standard medical
practice (alternative therapies). Use of
these therapies date back to early folk
medicine and are often based upon be-
lief systems stemming from religious
faith. Although the use of non-stan-
dardized home remedies for minor ill-
nesses is widespread, the emphasis in

modern-day medicine has been treat-
ment that is evidence-based. There has
been a growing trend toward the use of
scientifi cally unsupported approaches,
especially within the fi elds of chronic
illness and developmental disabilities.

In 1992, the U.S. government estab-
lished the National Center for Comple-
mentary and Alternative Medicine (NC-
CAM) through the National Institutes of
Health. The NCCAM recognizes fi ve do-
mains of complementary and alternative
medicine: alternative medicine systems
(eg, Chinese medicine), mind-body inter-
ventions (eg, meditation), biologically-
based medicine (eg, megavitamin ther-
apy), body-based therapies (eg, sensory
integration therapy), and energy therapies
(eg, magnet therapy) (see Table).

The prevalence of com-
plementary and alternative
therapy usage in children
with chronic illness, de-
velopmental disabilities,
and emotional problems
is high.1-3 These treat-
ments are often promoted
commercially. They also
generally lack objective,
evidence-based studies to
support their claims of ef-

fi cacy, often relying upon unproven the-
ories with results that are usually based
upon anecdotal cases. Commercial Web
sites or publications, instead of peer-re-
viewed, scientifi c journals, are the ve-
hicles promoting the information to the
public. Therapies reaching the attention
of the media may then be sensational-
ized, furthering their promotion. Often
pediatricians fi nd themselves in a diffi cult
position imposed by a parent requesting
their endorsement of an unsubstantiated
treatment.4 Recent studies found the use
of CAM to range between 50% to 92% in
the ASD population.5,6 Within the ASD
population, 50% of biologically-based
therapies utilized by parents involved
dietary changes.7 Seventy-six percent of
parents using dietary modifi cations felt

TABLE.

Types of Complementary
and Alternative Medicine

Domain Examples

Alternative medicine systems Chinese medicine, acupuncture

Mind-body interventions Meditation

Biologically-based medicine Megavitamins, elimination diets

Body-based therapies Sensory integration therapy

Energy therapies Magnet therapy

SIDEBAR.

Biologically-based Therapies

Elimination diets: Feingold diet, gluten- and casein-free diet, ketogenic diet

Vitamins and supplements: Vitamins A, B6, B12, C, folate, magnesium, dimethylglycine,
omega 3 fatty acids

Neurosecretory agents: Secretin, oxytocin

Famotidine (Pepcid)

Immunologically-based therapies:

Antibiotics: vancomycin

Antivirals

Antifungals based on the theory of yeast overgrowth (nystatin, fl uconazole)

Intravenous immunoglobulin G

Toxin removal: Chelation therapy based on theory of mercury toxicity

Non-biologically based treatments: Sensory integration therapy, facilitated
communication therapy, auditory integration therapy, hyperbaric oxygen therapy

•

•

•

•

3709Schechtman.indd 6403709Schechtman.indd 640 8/30/2007 10:09:48 AM8/30/2007 10:09:48 AM

PSYCHIATRIC ANNALS 37:9 | SEPTEMBER 2007 641

that these had been of some benefi t for
their affected child. In the category of
body-based therapies, chiropractic ther-
apy was most commonly used; however,
there was no real reported benefi t. Vari-
ous therapies were reported by parents
as helpful in relaxing the child diagnosed
with ASD, and these included therapeu-
tic horseback therapy (hippotherapy),
massage, music therapy, and sensory in-
tegration therapy.

This article will focus on many of
the biologically and non-biologically
based alternative or complementary
therapies used in the treatment of ASD
(see Sidebar, page 640).

BIOLOGICALLY-BASED THERAPIES

Diets: The Brain-Gut Connection
The potential relationship between

gastrointestinal symptoms and autism
has been the basis of much investigation
in this population. Valicenti-McDermott
et al8 reported a higher than expected
frequency of gastrointestinal
symptoms and food selec-
tivity in a sample of 50
children with ASD.
Increased symptoms
such as diarrhea, re-
fl ux, constipation,
bloating, etc., have
been reported with
frequencies of 9%
to 50% in this popu-
lation.9 Increased lev-
els of serotonin, a primary
gut neurotransmitter, have been
found in the plasma of people with au-
tism, but it is not clear that this is linked
to the gastrointestinal symptoms.10

In a small, double-blinded, placebo-
controlled study reviewed by Erickson,11
famotidine (Pepcid) was administered
to children with ASD and gastrointesti-
nal symptoms. Improved behavior was
noted; however, four of the nine chil-
dren noted to have behavioral improve-
ment had undiagnosed gastroesophage-

al refl ux disorder, which may have been
a factor in their improvement.

Dietary manipulation in the treat-
ment of developmental or behavioral
problems is not a new concept. The ori-
gin of this practice is beyond the scope
of this article. However, more recent
dietary practices based upon presumed
associations with nutritional excesses
and defi ciencies and possible effects
on behavior evolved in the 1920s, with
the suggestion of excessive sugar con-
sumption and the development of hy-
peractivity and impulsivity. The Fein-
gold diet,12 which became popularized
in the 1970s, was largely based upon
these theories.

In the 1970s, Panskepp13 proposed
that malabsorption of casein (a milk pro-
tein) and gluten (a wheat protein) might
be responsible for manifestations of au-
tism via altered cerebral neurotransmit-
ter metabolism. The protein metabolites
from milk and wheat products were

postulated to be absorbed through a
“leaky gut” and to act central-

ly as endogenous opioids;

however, the relationship
between opioid activity and the

development of autism remains specula-
tive. The fi nding of increased peptides
in the urine of children with autism14 is
controversial, as is the proposal that a
gluten- and casein-free diet can decrease
urinary peptides, resulting in increased
social interactivity among autistic chil-
dren. Despite the lack of defi nitive data,
the use of the gluten-/casein-free diet is
widespread with many anecdotal testi-
monials of its success.

Erickson11 also reviewed the use of
the ketogenic diet in a small population
of children with autism. Although im-
proved behavior was noted, the study
was not controlled. Dietary limitations,
such as those imposed by selective
elimination diets, may impose addition-
al stress on children and their families
and hypothetically may result in nutri-
tional defi ciencies.

In 1998, Horvath’s report on im-
proved developmental/behavioral func-
tion following secretin administration
to children with gastrointestinal com-
plaints and symptoms of autism added
to the growing number of theories of
brain-gut interaction based upon gas-
trointestinal proteins acting as central
neuropeptides in the brain.15 However,
despite the initial excitement of se-
cretin as a treatment in ASD, multiple
well-controlled, peer-reviewed stud-
ies on more than 700 children did not
bear out the treatment effects initially
reported by Horvath.

In 2002, Wakefi eld16 reported a case
series of endoscopic studies on children

with autism and gastrointestinal symp-
toms. An increased rate of ileal lym-
phonodular hyperplasia and colitis was
reported. This article has since been re-
tracted by almost all of the authors.

The Immune System Connection
Abnormal immune function in chil-

dren with ASDs has included the fi nd-
ings of increased antibodies, abnormal
cytokines, antibodies to myelin basic
protein, abnormal immune responses,
and a reported increased prevalence of

The U.S. Institute of Medicine report …
concluded that there is no evidence linking the

MMR vaccine with autism.

3709Schechtman.indd 6413709Schechtman.indd 641 8/30/2007 10:09:48 AM8/30/2007 10:09:48 AM

642 PSYCHIATRIC ANNALS 37:9 | SEPTEMBER 2007

lymphonodular hyperplasia in a previ-
ously diagnosed population of children
with ASD.16-18 Despite suspicion of im-
mune or autoimmune dysfunction in
children with ASD based upon reports of
increased gastrointestinal symptoms, ear
infections, and allergies, no increase in
the rate of either ear infections or allergic
responses, has been noted.19,20 However, a
recent report revealed a higher family his-
tory of autoimmune disorders (rheuma-
toid arthritis, celiac disease, and infl am-
matory bowel disease) in a population of
children with ASD and gastrointestinal
symptoms who had undergone language
regression, compared with those without
language regression.21

IS IT VIRAL?
Levy and Hyman’s 2005 review22 cited

investigational reports of evidence of early
infection, chronic infl ammation, or au-
toimmune disorders as possible etiologic
factors in ASD. They commented that
prenatal and neonatal exposure to viruses
is postulated to alter brain development;
however, studies of viral exposure failed
to show an infl ammatory response in the
brain. Antiviral agents have been proposed
as a treatment strategy; however, no spe-
cifi c virus has been identifi ed, and no pub-
lication has addressed antiviral therapies
in terms of effi cacy or safety in ASD.

In 1998, Wakefi eld16 reported on 12
cases of children with GI abnormalities
and lymphonodular hyperplasia, and
eight of the 12 children allegedly dem-
onstrated symptoms of autism reported
to develop soon after receipt of an MMR
vaccination. Although Wakefi eld did
not prove an actual causal connection
between autism and MMR, public con-
cern nonetheless exploded after this was
reported on 60 Minutes. Madsen et al23
using national-registry data on autistic
disorders in Denmark (a national cohort
study including 537,000 children) found
no association between the MMR vac-
cine and the subsequent diagnosis of au-
tism. In March 2004, 10 of Wakefi eld’s

co-authors published a formal retrac-
tion of the suggestion of a link between
MMR and autism in The Lancet.24 The
U.S. Institute of Medicine report co-
sponsored by the National Institutes of
Health and the Centers for Disease Con-
trol and Prevention concluded that there
is no evidence linking the MMR vaccine
with autism.25

IS IT BACTERIAL?
Sandler et al26 used the antibiotic van-

comycin in a small study of 11 children
with autism and diarrhea whose stools
were colonized with a different clostridi-
um species than controls. It was suggested
that neurological symptoms might result
from altered gut integrity on the basis of
toxins in altered colonic fl ora. However,
outcome parameters of this study were
not totally blinded, and the children’s be-
haviors may have improved because of
improved bowel function alone.

IS IT FUNGAL?
In the 1980s, anecdotal reports impli-

cated overgrowth of the yeast Candida
albicans in precipitating some cases
of autism. Crook27 suggested the over-
growth of yeast to be secondary to anti-
biotic use or ingestion of processed sug-
ars. Candidal overgrowth was, however,
not documented by endoscopic study.16
The yeast theory popularized the use of
treatments to reduce yeast colonization,
which included the use of probiotics (ac-
idophilus, lactobacillus), dietary modifi –
cation (reduction of refi ned sugars), and
the use of antifungal agents like nystatin
and fl uconazole.

IS IT PRIMARY
IMMUNODEFICIENCY?

Levy and Hyman22 reviewed three
small case series of ASD with equivo-
cal results after intravenous immu-
noglobulin G (IVIG) administration.
However, because of the small risk of
blood-borne infection and side effects
of IVIG, they recommended that this

agent be used for diseases where there
was documented benefi t.

IS IT HEAVY METAL TOXICITY?
Bernard et al28 drew attention to sim-

ilarities between symptoms of autism
and mercury toxicity, suggesting a con-
nection between environmental sourc-
es of mercury and the development of
autism. However, mercury poisoning is
characterized by severe movement dis-
orders and peripheral nerve damage,
none of which is typically found in
children with ASD. Nonetheless, me-
dia reports led to requests for mercury
testing because of growing concerns
of possible toxicity. Mercury, a heavy
metal found in the environment, accu-
mulates in internal organs. Therefore,
blood and urine assays do not always
reveal mercury exposure. Hair trace
analysis, which has not been standard-
ized, is not considered to be a reliable
assay for mercury toxicity because of
differing rates of hair growth, variable
hair composition, and because sham-
poos, hair products, exposure to sun,
and drying all serve to leach substances
from hair. Thimerosal, an ethyl-mer-
cury based preservative once used in
many vaccines in the United States (in-
cluding the MMR vaccine), was sug-
gested as a possible cause of autism
in a subpopulation of immunized chil-
dren. Other sources of mercury such as
that contained in thermometers, mer-
cury amalgams in tooth fi llings, and
some fi sh came under scrutiny in the
search for environmental precipitants
of autism symptoms. Pregnant women
were issued warnings against exces-
sive fi sh consumption, and amalgam
removal was even suggested. Madsen
et al23 examined the use of thimerosal-
containing vaccines and ASD in Den-
mark, where thimerosal was removed
from vaccines in 1992. This study
demonstrated that despite removal of
thimerosal from vaccines, the numbers
of autism cases continued to rise at

3709Schechtman.indd 6423709Schechtman.indd 642 8/30/2007 10:09:50 AM8/30/2007 10:09:50 AM

PSYCHIATRIC ANNALS 37:9 | SEPTEMBER 2007 643

the same rate as prior to its removal.
Studies of children who received heavy
metal chelation failed to demonstrate
improved neurodevelopmental func-
tion on follow-up.29 More ominous
was the documentation of two deaths
in children in the United States (one of
whom had autism) because of
hypocalcemia and cardiac
arrest after undergo-
ing chelation thera-
py.30 The American
Academy of Pedi-
atrics (AAP) and
the Public Health
Service published
a statement in 2001
indicating the lack of
a decrease in the prev-
alence of autism despite
the removal of thimerosal.31
Although there is no evidence for
mercury’s role in causing ASD, chela-
tion therapy has been utilized as a de-
toxifi cation procedure, with occasion-
ally disastrous results.

VITAMINS AND NUTRITIONAL
SUPPLEMENTS

Nutritional supplements have also been
popularized in the treatment of symptoms
in children with ASD. Megavitamin ther-
apy gained popularity in the 1960s with
Linus Pauling’s theory linking mental ill-
ness and inborn errors of metabolism.32 A
variety of vitamins (vitamins A, C, B6-
magnesium complex, folic acid, B12) and
minerals have been advocated.

Vitamin B6-magnesium complex has
been the most heavily promoted of the
vitamin therapies for ASD. Vitamin B6
(pyridoxine) has been advocated because
of its cofactor role in the production of
the neurotransmitters: serotonin, norepi-
nephrine, epinephrine, dopamine, and
GABA. Magnesium may have an addi-
tive effect on this. Rimland33 reported
decreased behavioral outbursts in autism
with vitamin B6-magnesium supple-
mentation, based on more than a dozen

studies at that time, many of which were
not blinded or adequately controlled. In
a review of the literature in 2002, Nye
and Brice34 concluded that no recom-
mendation could be made for this treat-
ment based upon the scant data available.
Caution is advised because excessive in-

take of pyridoxine is associated
with peripheral neuropathy.

Excessive magnesium
concentrations are associated

with the development of seizures.
Vitamin A, such as that found in

cod liver oil, is promoted as improv-
ing immune function and vision in
children with autism; however, no
data are available. Excessive use of
Vitamin A can lead to hepatotoxicity
and increased intracranial pressure.

Vitamin C (ascorbic acid) was
reported in one trial to decrease ste-
reotypic behaviors significantly in a
study of residential students with au-
tism; however, this study was never
replicated.35 Vitamin C in excessive
doses has the potential to cause diar-
rhea and renal stones.

Vitamin B12 treatment was recom-
mended based upon data from a small,
controlled study of 20 children with
autism found to have lower plasma con-
centrations of the antioxidants methio-
nine, homocysteine, total glutathione,
cysteine, and S-adenosylmethionine as
compared with controls.36 Administra-
tion of subcutaneous vitamin B12 and
oral folinic acid to patients with ASD
is based on the premise that these indi-
viduals have compromised antioxidant
defenses with an inability to detoxify

environmental contaminants. This study
suggested that as plasma concentrations
of the antioxidants increased, behaviors
were noted to improve; however, further
studies have not replicated this data.

Dimethylglycine (DMG, a nutritional
supplement) is metabolized to the excit-
atory neurotransmitter, glycine, within the
liver. There have been reports of an old

Russian study, which suggested enhanced
language skills in developmentally disabled
children who were administered DMG;
however, two well-controlled and blinded
studies in ASD failed to demonstrate a dif-
ference between DMG and placebo.37,38

Omega-3 fatty acids or polyunsatu-
rated fatty acid (PUFA) 39 is a popular
treatment for a variety of developmental
problems including attention-defi cit/hy-
peractivity disorder, dyslexia, develop-
mental coordination disorder, and ASD.
The results of controlled treatment trials
have been mixed and are hard to inter-
pret because of differing formulations
of the essential fatty acids and different
populations treated. Larger clinical trials
are needed to corroborate the fi ndings of
a few reports of improved behaviors.

Oxytocin intranasally and intrave-
nously may have signifi cant positive
effects on repetitive behaviors and so-
cial cognition in adult autism patients;
however, the signifi cance of these re-
sults needs further investigation as
studies on adults cannot be general-
ized to children.40

Other Supplements
Levy and Hyman reviewed data on

other supplements such as tryptophan,

Although there is no evidence for mercury’s
role in causing ASD, chelation therapy has been

utilized as a detoxifi cation procedure, with
occasionally disastrous results.

3709Schechtman.indd 6433709Schechtman.indd 643 8/30/2007 10:09:50 AM8/30/2007 10:09:50 AM

tyrosine, cyproheptadine, D-cycloser-
ine, and carnosine. There is need for
additional research to support the use
of these supplements.22

NONBIOLOGICAL INTERVENTIONS

Sensory Integration Therapy
Ayres, an occupational therapist, pos-

tulated in 1979 that children with ASD
have defi cits in the brain areas responsi-
ble for processing sensory input (visual,
tactile, auditory, gustatory, vestibular,
and proprioceptive) and motor output.41
Sensory integration activities include
jumping on trampolines, swinging, spin-
ning the body, rolling the body, riding a
scooter board, balance activities, appli-
cation of brushes to the body, the wear-
ing of weighted vests, “smooshing” a
child between pads or pillows, and play-
ing with textured toys. Oral motor activ-
ities may be used as well. Manipulation
of the environment is central to sensory
integration therapy; therefore, the fabric
(texture) of clothing or sheets may be
changed. Labels and tags are removed
from clothing, and class sizes are limited
to decrease distraction. Within the class-
room, a quiet corner is established to pro-
vide an area with decreased stimulation.
Occupational therapists commonly pro-
vide sensory integration therapy, which
may take place in differing venues, such
as in the home or school. Anecdotal evi-
dence for effi cacy of sensory integration
therapy is widespread, and there is great
interest in establishing an evidence-base
for these therapies.

There is ongoing research evaluating
the use of water therapy (aquatherapy),
horseback riding (hippotherapy), music
(music therapy), massage, and other
therapies, which claim to calm and im-
prove behavioral symptoms in children
with ASD and other disabilities.

Facilitated Communication
Facilitated communication (FC) refers

to an intervention utilizing either a com-

puter or typewriting device in which an-
other individual, the facilitator, guides the
hand of a nonverbal individual. This tech-
nique was originally used to assist physi-
cally disabled individuals.42 Numerous
controlled and blinded studies have failed
to demonstrate FC as replicable or valid.
In 1998, the AAP issued a statement from
the Committee on Children with Disabili-
ties highlighting the lack of scientifi c data
to show FC to be effective.43

Auditory Integration Training
Auditory integration training (AIT)

is a technique conceived by a French
ENT specialist, Dr. Guy Berard, in
the 1960s. It consists of acoustically
modifi ed music played to a child for 10
hours in two 30-minute sessions each
day from a CD player attached to box
(AIT device) that is wired to modify the
signal, presumably to reduce the vol-
ume for frequencies to which the child
is hypersensitive. It was publicized as a
method to “retrain” the auditory system
in children with auditory sensitivities
and became popularized by the book
“The Sound of a Miracle” by Stehli.44
Gravel45 stated that there was no scien-
tifi c evidence for the type of peripheral
hearing abnormalities that Berard orig-
inally reported. In addition, the sound
pressure levels produced by some of the
AIT devices were potentially unsafe.
The 1998 statement of the AAP, which
addressed Facilitated Communication,42
also indicated the lack of scientifi c evi-
dence and potential danger of Auditory
Integration Training, recommending its
use in experimental protocols only.

Hyperbaric Oxygen Therapy
A review of hyperbaric oxygen ther-

apy (HBOT) indicates successful use of
this therapy in improving perfusion and
healing in wounds (diabetes), carbon
monoxide poisoning, and decompres-
sion illness in sports divers.46 HBOT has
been used for the treatment of cerebral
palsy, fetal alcohol syndrome, traumatic

brain injury, and ischemic brain injury.
It was postulated that decreased blood
perfusion to several areas of the brain,
in particular the temporal regions and
auditory processing and language areas,
correlate with many of the behaviors as-
sociated in autism.47 However, scientifi c
evidence is lacking for the use of HBOT
in developmental disabilities.

SUMMARY
Our understanding of ASD has

changed over the past decades, and di-
agnostic tools have assisted in earlier
identifi cation and referral for interven-
tion. Appropriate intervention appears
to impact positively on overall outcome
for a pervasive developmental disorder
for which there is currently no known
cure. Novel and controversial thera-
pies will come and go, and therefore
physicians should familiarize them-
selves with these interventions, as ad-
vice about these alternative approaches
will be sought. Discussions of nontra-
ditional therapies should include the
placebo effect, possibly undesirable,
or potentially dangerous outcomes of a
treatment, and the importance of scien-
tifi cally sound research studies of that
treatment. Addressing the use of com-
plementary and alternative therapies in
families with medically compromised
or developmentally disabled children
is crucial to providing complete care to
the patient.

A note from the editors:
This article originally appeared in

Pediatric Annals, a SLACK Incorporat-
ed publication.

REFERENCES
1. Fombonne E, Simmons H, Ford T, Meltzer

H, Goodman R. Prevalence of pervasive
developmental disorders in the British
nationwide survey of child mental health.
J Am Acad Child Adolesc Psychiatry.
2001;40(7):820-827.

2. McCann LJ, Newell SJ. Survey of paediatric
complementary and alternative medicine
use in children in health and chronic ill-
ness. Arch Dis Child. 2006;91(2):173-174.

644 PSYCHIATRIC ANNALS 37:9 | SEPTEMBER 2007

3709Schechtman.indd 6443709Schechtman.indd 644 8/30/2007 10:09:52 AM8/30/2007 10:09:52 AM

PSYCHIATRIC ANNALS 37:9 | SEPTEMBER 2007 645

3. Levy SE, Mandell Ds, Merhar S, et al. Use
of complementary and alternative medi-
cine among children recently diagnosed
with autistic spectrum disorder. J Dev Be-
hav Pediatrics. 2003;24:418-423.

4. Eisenberg DM. Advising patients who seek
alternative medical therapies. Ann Intern
Med. 1997;127(1):61-69.

5. Hanson E, Kalish LA, Bunce E, et al. Use of
complementary and alternative medicine
among children diagnosed with autism
spectrum disorder. J Autism Dev Disord.
2007;37(4):628-636.

6. Harrington JW, Rosen L, Garnecho A, Patrick
PA. Parental perceptions and use of comple-
mentary and alternative medicine practices
for children with autistic spectrum disorders
in private practice. J Dev Behav Pediatr.
2006;27(2 Suppl):S156-161.

7. Wong HH, Smith RG. Patterns of complemen-
tary and alternative therapy use in children
diagnosed with autism spectrum disorders. J
Autism Dev Disord. 2006;36(7):901-909.

8. Valicenti-McDermott M, McVicar K, Rapin I,
Wershil BK, Cohen H, Shinnar S. Frequency of
gastrointestinal symptoms in children with au-
tistic spectrum disorders and association with
family history of autoimmune disease. J Dev
Behav Pediatr. 2006; 27(2 Suppl):128-136.

9. Kuddo T, Nelson K. How common are gastro-
intestinal disorders in children with autism?
Curr Opin Pediatr. 2003;15(3):339-343.

10. Goyal R, Hirano I. Mechanisms of disease:
the enteric nervous system. N Engl J Med.
1996;334(17):1106-1115.

11. Erickson CA, Stigler Ka, Corkins MR, Posey
DJ, Fitzgerald JF, McDougle CJ. Gastrointesti-
nal factors in autistic disorder: a critical review.
J Autism Dev Disord. 2005;35(6):713-727.

12. Feingold BF. The role of diet in behaviour.
Ecol Dis. 1982:1(2-3):153-165.

13. Panskepp J. A neurochemical theory of autism.
Trends in Neuroscience. 1979:2:174-177.

14. Reichelt K, Ekerm J, Scott H. Gluten, milk
proteins and autism: dietary intervention ef-
fects on behavior and peptide secretion. J Appl
Nutr. 1990;42:1-11.

15. Horvath K, Stefanatos G, Sokolski KN, Wach-
tel R, Nabors L, Tildon JT. Improved social and
language skills after secretin administration in …